Data
Collection Form
Haverhill Public Library
Community Information and Referral Database
Please print this form out, and answer all questions
that apply to your organization. If you need assistance filling out this form,
please contact the Reference Department at the
Haverhill Public Library,
(978) 373-1586 x608
Organization Name:
_______________________________________________________________
Also Known As:
_________________________________________________________________
Address: _______________________________________________________________________
Phone: _________________________________ Fax:
__________________________________
Website Address:
_______________________________________________________________
Contact Person:
_____________________________Title ________________________________
Contact’s Phone:
________________________________________________________________
Email Address for Contact Person or General Info
_________________________________________
Hours or meeting times:
___________________________________________________________
Location of meetings:
_____________________________________________________________
Area served:
____________________________________________________________________
Eligibility requirements (Indicate “NONE” or describe):_____________________________________
_______________________________________________________________________________
Language spoken (excluding English):
___________________________________________________
Funding/Fees:
_____________________________________________________________________
Do you accept volunteers? What are their duties?:
________________________________________________________________________________
Organizations with which you are affiliated:
________________________________________________________________________________
Publications of Organization (include frequency and titles):
________________________________________________________________________________
Does your organization offer scholarships?:
_______________________________________________
If yes, what are the eligibility requirements?:
_______________________________________________
Physical facility – is your site handicapped accessible or available for public
use?: _____________________
Brief Synopsis of Organization:
________________________________________________________________________________
_________________________________________________________________________________
Additional Information:
________________________________________________________________________________
_________________________________________________________________________________
We make every effort to update our files annually. What month is best to
contact you to update this information?
_________________________________________________________________________________
This information will be made available to the public through the Merrimack Valley Library Consortium computer database, located online at http://webserv.mvlc.lib.ma.us/ipac-cgicomres/ipac. Please sign below to indicate that you are aware of the nature of our use of this information.
_________________________________________________________________________________
Name
Date
Please return this form to:
Haverhill Public Library
99 Main Street,
Haverhill MA 01830
or FAX it to: 978-373-8466
Thank you for your time!
updated
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