Tactile Image Interest Form

Organization NameOrganization Nametrue

Art MuseumHistoryfalseNatural History MuseumtrueSciencefalsefalsefalseOtherChildren's MuseumNatural HistoryArtLibraryPlanetarium or ObservatoryPlanetarium or ObservatoryChildren'sfalseNature Center or ParkotherLibraryAquarium, Botanical Garden, or Zoofalse10Organization TypefalsefalseHistory MuseumNature Center or ParkScience/Technology Center or MuseumOrganization TypeAquarium, Botanical Garden, or Zoofalsefalsefalse

falseOther Organization TypeotherfalseShow1Organization Typefalse

Other Organization TypeOther Organization TypeEnter your organization typeothertrue

Organization Annual AttendanceOrganization Annual Attendancetruenumeric

Large City (>250,000)suburbansmall cityruralMid-sized City (100,00-250,000)falsefalse5Organization SettingfalsefalsefalsefalseSuburbanSmall City (<100,000)large cityRuralOrganization Settingmid-sized citytrue

falsefalseNononon-profityestrueYes2Is the Organization a non-profit?false

Point of ContactPoint of Contacttrue

Point of Contact's Job TitleJob Titletrue

Point of Contact's Email AddressEmail Addresstrueemail

Mailing Address

Please include the mailing address the panel should be shipped to if your organization is picked to receive one.

Street AddressStreet Addresstrue

Street Address 2Street Address 2

CityCitytrue

falsemediumFieldPuerto RicoSDWashingtonWYfalsefalseGUMDfalsefalseNJPRtruefalseWAWyomingDistrict of ColumbiaNorth CarolinaSouth DakotaVIOHMinnesotaMNMTILGuamMarylandNew JerseyNCfalseMontanafalseARfalseAlaskafalseUS Virgin IslandsfalsefalsefalsefalseAKfalseIAAlabamaTXfalseMichiganNew YorkNMMAfalseFloridafalseOregonVermontALCTIowaTexasfalsefalseFLfalsefalseConnecticutORVTGAMassachusettsTNKSColoradofalsefalseKansasfalsefalsefalseCOGeorgiaVAfalseVirginiaNYTennesseeNEOklahomafalseKentuckyNebraskaUtahfalsefalseCaliforniafalseDEfalsefalseAmerican SamoafalseCAfalseNew MexicoNDfalseHawaiiINMEWest VirginiafalsefalseNorth DakotaOKfalseMaineMIDelawarePennsylvaniaPASCstatefalseIndianaKYfalseIdahoAZSouth CarolinafalseWisconsinfalseMOMPNevadaLouisianaRIHIfalsefalseWVArkansasMissouriNorthern Mariana IslandsfalsefalseLANVfalseMSRhode IslandfalseASfalseIllinoisNHDC56State, district, or territoryOhiofalseArizonaIDfalsefalsefalsefalseNew HampshireWIfalseMississippiUT

Zip CodeZip Codetruenumeric

Extra LargeIntended Use or Description of Audience Need (approximately 50 words)Intended Usetrue

When do you anticipate first being able to use the panel?First Usetrue

falsefalseNonoDo you agree to provide information via email about your experience with the panel within two weeks of your first use? (approximately 100-200 words)yestrueYes2Provide Feedbackfalse