Request for Access to a Restricted Collection

                              
                                                      Date:___________________________

Name of Collection:___________________________________________________________________

Topic of Research:____________________________________________________________________

______________________________________________________________________________________

Purpose of Research:__________________________________________________________________

______________________________________________________________________________________

Researcher's Name:____________________________________________________________________

Mailing Address:______________________________________________________________________

                ______________________________________________________________________
                
                ______________________________________________________________________

Email Address:  ______________________________________________________________________

Telephone Number: Area Code (            )____________________________________________

Institutional Affiliation (if any):___________________________________________________

Position Title:_______________________________________________________________________


----------------------------For Library Staff Use Only:-------------------------------
Researcher requested permission:                         Decision:
___ By email                                             ___ Permission granted
___ By fax                                               ___ Permission denied
___ By letter
___ By telephone                                         Requester notified by:___________
___ In person                                            ___ By email
                                                         ___ By fax
Permission requested by:______________                   ___ By letter
___ By email                                             ___ By telephone
___ By fax                                               ___ In person
___ By letter
___ By telephone                         Permission recorded in card file in Reading Room:
                                         Date______________________________________
                                         By________________________________________

       When completed, this file is to be filed in collection case file