 |
|
 |
|
 |
| Her Majesty Queen Margrethe II of Denmark, Protector |
 |
 |
 |
| The Danish Immigrant Museum 2212 Washington Street P.O. Box 470 Elk Horn, Iowa 51531-0470 712.764.7001 © Since 1983; All Rights Reserved |
 |
| RESEARCH REQUEST FORM Print and complete this form; mail with payment to: The Danish Immigrant Museum Family History & Genealogy Center Research Request 4210 Main Street P.O. Box 249 Elk Horn IA 51531-0249 _________________________________________________________________________ Date: _____________________ Your Name: _____________________________________________________ Mailing Address: _________________________________________________ City: _______________________________ State: _________ ZIP: _________ Phone: ___________________________ E.Mail: _______________________ _________________________________________________________________________ Payment Information: Research fees: $20 per hour for Museum members; $30 per hour for non-members. A $5 postage/handling fee will be added to all requests. Maximum number of hours authorized: _________ Form to be accompanied by a minimum 2-hour retainer. [ ] A check or money order for $ _________ is enclosed. [ ] I authorize my credit card to be billed for $ _______________. MasterCard _______ Visa _______ Card # __________________________________ Exact Name On Card: ________________________________________________ Expiration Date: ___________ Signature: ___________________________________________ (Date) _________ _________________________________________________________________________ Research Information Requested (Provide detailed information.): Name of Individual: ___________________________________________________ B: _____________________ Place: _______________________________________ D: _____________________ Place: _______________________________________ M: _____________________ Place: _______________________________________ To (Spouse): __________________________________________________________ B: _____________________ Place: _______________________________________ D: _____________________ Place: _______________________________________ Emigrated: ___________________ from: ___________________________________ Residences in U.S.: _____________________________________________________ Known Children/Siblings (circle one): Name: ______________________________ B: _______________ D: ____________ Name: ______________________________ B: _______________ D: ____________ Name: ______________________________ B: _______________ D: ____________ Information Wanted: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ (Continue listing information on the back of form, or; as an additional documentation when needed.) _________________________________________________________________________ For Office Use Only: Received By: _____________________ Initials: ________________ Date: ____________ Completed By: _____________________ Initials: ________________ Date: ____________ |
|