Santa Clara City Information Network
Database Submission Form (print, fill out, and return)City Dept./Agency/Organization/Club:
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Acronym (or other name Agency/Organization/Program known as):
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Street Address:
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Cross Street:_________________________________________
Mailing Address (P.O. Box, or if different from above):
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Phone:_____________________________________________________________
Fax:_______________________________________________________________
TTY/TDD (for hearing impaired):___________________________
E-Mail:_________________________________________
Website:_______________________________________
Days and Hours Service is Available:
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Contact Information:
Name:_____________________________________________________________
Title:_______________________________________________________________
Phone:_____________________________________________________________
E-mail:_____________________________________________________________
Mission/Purpose (briefly describe major purpose of Department/Organization/Program):
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Services/Functions (list and briefly describe major services and activities):
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Eligibility Requirements (Serve people in Santa Clara only? Age, income, or geography restrictions? Others? or, open to all?):
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Cost/Fees (for joining or use of service):
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Wheelchair Accessible? (circle one):__YES____NO____PARTIALLY____
Publications (e.g. Title of: guides, brochures, newsletter; include frequency published):
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Languages Spoken (other than English, as a regular part of service):
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Public or Regular Club Meetings, if any (Location, Frequency):
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Thank you for filling out this questionnaire. (Search our database on the Internet at: http://www.sccl.santaclaraca.gov:81/screens/opacmenu.html). If you need additional information or forms, please call 408-615-2910. Please Fax back completed form to: 408-246-9581, or mail back to:
Santa Clara City Library
City Information Network Database Staff
2635 Homestead Road
Santa Clara, CA 950512/05 Santa Clara Library C.I.N. data collection form