OMB Control No. 3095-0074 Expiration date: 07/31/2027 Please complete the form below to submit a programming reservation request to the Ford Museum in Grand Rapids, MI. Please fill in all fields marked with a (*required). Institution/Organization Title I - Select -YesNo Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Contact Name Contact Email Address Primary Phone Alternate Phone Number of Students Number of Chaperones For every 10 students, we require 1 adult chaperone. Additional chaperones are charged museum admittance fee: $10.00 for adults. Grade Level * Please select three dates for your visit: Must be at least two weeks from today’s date. First Choice Date Date: Date Date: Time Second Choice Date Date: Date Date: Time Third Choice Date Date: Date Date: Time Program Selection - Select -Docent-Guided Tour (maximum 30 students)Self-Guided Tour (no maximum number of students) Onsite Guided is available Monday through Saturday, 10:00 a.m. to 5:00 p.m and Sunday, 12:00 p.m. to 5:00 p.m. Self-Guided available Monday through Saturday, 10:00 a.m. to 5:00 p.m. and Sunday, 12:00 p.m. to 5:00 p.m. Comments Questions can be submitted to fieldtrip@nara.gov, or by calling (616) 254-0400. You should receive a response within five business days. Privacy Act Statement and Paperwork Reduction Act Public Burden StatementCollection of this information is authorized by 44 U.S.C 2104. The information you provide to NARA on this form will be used to manage attendance, registration and communication for and about NARA’s learning program. This information is necessary in order to efficiently administer the program. Completing this form is voluntary. If you do not provide this information, NARA may not be able to process your request to participate in our education events and distance learning opportunities. In accordance with the Privacy Act, 5 U.S.C. 552a(e)(4)(D), NARA may disclose this information to: appropriate Federal, state, local, or foreign agencies when needed for civil, criminal, or regulatory investigations or prosecution; in response to a request from another Federal agency or Congress; to a NARA consultant, agent, or contractor to the extent necessary for them to assist NARA in the performance of its duties; or in accordance with any other “routine uses of records” listed in the Privacy Act System of Records Notice NARA 5, “Conference, workshop, and training course files.You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Public burden reporting for this collection of information is estimated to be less than 10 minutes per response. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (MP), 8601 Adelphi Rd, College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.
