Herbarium Speciment Loan Request Form

Date: (MM/DD/YY)

Type of Specimen: - please select specimen - Bryophytes Fungus Vascular Plants

Borrower's Full Name:

Title/Position:

Institution Name:     Institution Acronym:

Address 1:

Address 2:

Address 3:

City, ST, Zip: ,

Country:

Email:

Phone:

Researcher's Full Name:

Researcher's Title/Position:

Descriptions of Specimens and Remarks:

Please provide as much detail as possible.
(i.e. specimen numbers, locations, geographic scope, synonyms, expected term of loan, etc.)