Request for Access to a Restricted Collection

                              
                                Date:___________________________

Name of Collection:_____________________________________________

Topic of Research:______________________________________________

________________________________________________________________

Purpose of Research:____________________________________________

________________________________________________________________

Researcher's Name:______________________________________________

Mailing Address:________________________________________________
                ________________________________________________
                ________________________________________________

Telephone Number: Area Code (    )______________________________

Institutional Affiliation (if any):_____________________________

Position Title:_________________________________________________

----------------------For Library Use Only:----------------------
Researcher requested permission:
___ By letter
___ By telephone
___ In person

Permission requested by ________________________________________
___ By letter
___ By telephone

Decision:
___ Permission granted
___ Permission denied

Requester notified by __________________________________________
___ By letter
___ By telephone
___ In person

Permission recorded in card file in Reading Room:

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