Scope-on-a-Rope - Loan Request

Thank you for your interest in the Furman Scope-on-a-Rope program.

Please select all that apply to your request.

Please select all that apply to your request. Get additional information about the Furman Scope-on-a-Rope program. Borrow one or more of the microscopes. Schedule a time for Dr. Kaup to come out to your school and demo the microscopes.
Name Name First Last
School
Grade level and/or subjects you teach.
School Address School Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
School Phone School Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email
Preferred contact method
Date you would like to use the microscope (if known). Date you would like to use the microscope (if known). / MM / DD YYYY
Date you woul like to return the microscope (if known). Date you woul like to return the microscope (if known). / MM / DD YYYY
Feel free to add any additional comments: