Application to use Facilities for Research

Physical Address	Campus Address
Edward J. Meeman Biological Station (MBS) 1250 Cuba-Millington Road Department of Biological Sciences The University of Memphis Millington, TN 38053 Email mbs@memphis.edu Phone 901.678.2605	Edward J. Meeman Biological Station (MBS) 3700 Walker Avenue Department of Biological Sciences The University of Memphis Memphis TN 38152 Phone 901.678.3749

First Name*

Last Name*

Address (Include City, State, and Zip Code)*

Home Institution or Organization*

Department*

Title or Academic Status (e.g., professor, graduate student)*

Major Professor or Mentor (if student)

Work Phone (with area code)*

Fax (with area code)

Other Phone (with area code)

Email*

Vehicle Make*

Vehicle Model*

Vehicle Year*

Vehicle Tag Number*

State Issued*

Research Project Information

Title of Proposed Project*

Proposed Start Date*

Proposed End Date*

IACUC Number (if applicable)

Scientific Collecting Permit Number - State

Scientific Collecting Permit Number - Federal

Short description or outline of project*

Physical Facilities Required

Fields/Trails

Classroom

Laboratory

Dormitory

Kitchen

Specify Other Facilities Required

Area of MBS where course or event will be conducted (include geolocation, if possible)*

Type of flora or fauna to be collected*

Extent of collecting proposed*

Disposition of collections*

Is Housing Needed?

Yes

Number of accompanying persons*

Bill To (if applicable)

Physical Address