Facilities for Teaching

First Name*

Last Name*

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

Home Institution or Organization*

Department*

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

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*

Course Information

Title and Number of Course or Event*

Proposed Start Date*

Proposed End Date*

Frequency of Use

One-time only

Once/Week

Several times/week

Daily

Specify Other Frequency

Time of Day

Before 6:00 a.m.

6:00 a.m. to Noon

Noon to 6:00 p.m.

After 6:00 p.m.

Specify Other Time of Day

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)*

Short description of course or event including how facilities will be used*

Will animals or plants be collected?

Yes

No

Is Housing Needed?

Yes

No

Number of accompanying persons*

Bill To (if applicable)

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

Application to use Facilities for Teaching or other Education Purposes

Physical Address

Campus Address