Conservator_Qualifications_Questionnaire_(CQQ).pdf

GSA CONSERVATOR QUALIFICATIONS QUESTIONNAIRE (CQQ)

FIRST

NAME: _________________________________________________________________________

LAST NAME:

POSITION: __________________________________________________________________________

FIRM NAME:

ADDRESS: _________________________________________________________________________

CITY: ___________________________________ STATE: ________ ZIP: _______________

PHONE: Home:________________ Studio: ______________ FAX: _________________

FUNCTION: ___ Conservator ___ Conservation Technician ___ Exhibit Designer ___ Framer ___ Other

SPECIALTY: MEDIA/MATERIALS:

___ Architecture ___ Books and Paper ___ Electronic media ___ Objects

___ Paintings ___ Photographic materials ___ Textiles ___Wooden artifacts

Describe your Conservation specialty and include specific materials you have specialized knowledge. Attach separate sheet as necessary.

EDUCATION: DEGREES __ ____________________________________________

(BA) (Name of School, degree and date of commencement)

(MA) (Name of School, degree and date of commencement)

(Ph.D.) (Name of School, degree and date of commencement)

INTERNSHIPS/APPRENTICESHIPS ____________________________________________________

PROFESSIONAL ___ FELLOW- American Institute for Conservation of Historic and Artistic Works of Arts

AFFILIATIONS:

___ PROFESSIONAL ASSOCIATE-

American Institute for Conservation of Historic and Artistic Works of Arts

___ Other (Specify) _________________________________

GEOGRAPHIC AREA OF INTEREST: Arranged by GSA Region.

___ 1 Maine, New Hampshire, Vermont Massachusetts, Connecticut, Rhode Island ___ 2 New York, New Jersey, Virgin Islands ___ 3 Pennsylvania, Maryland, West Virginia, Delaware ___ 4 Kentucky, Tennessee, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Florida ___ 5 Michigan, Wisconsin, Illinois, Indiana, Ohio ___ 6 Iowa, Nebraska, Kansas, Missouri ___ 7 Arkansas, Louisiana, Oklahoma, Texas, New Mexico ___ 8 Montana, North Dakota, South Dakota, Wyoming, Utah, Colorado ___ 9 California, Nevada, Arizona, Hawaii ___ 10 Washington, Oregon, Idaho ___ NCR District of Columbia, Maryland: Montgomery & Prince George’s Counties Virginia:

Arlington, Fairfax, Loudon, Prince William Counties, City of Alexandria

MAJOR CONSERVATION PROJECTS: Attach separate sheet as necessary.

AWARDS/GRANTS: