Exhibitor Name:
Department:
Professor/ Supervisor/ Sponsor:
Project Description (also fill in the applicable safety info below):
Date(s) and Time(s) that the exhibit/ project will be displayed :
Location of Exhibit requested:

If the space administrator approves this request, they will change location requested to approved by (their name & dept), then forward this to safe-project@mit.edu and copy the exhibitor. If the space can not be used, the space administrator will reply to the exhibitor.
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Exhibit Information reviewed by the Space Administrator and Safety Program
____Size: dimensions, at or above ground level, weight?
____What materials will be used and are these treated with fire retardant?
____Will it be constantly attended? Is it interactive?
____Any moving parts, sharp edges or points? How will these be protected?
____If electricity, pressure, etc will be used, how will it be de-energized and made safe?
____I plan to remove, dispose &/ or clean-up my project by (exhibitor fills in date)

Safety Program’s recommendations:
____Move project to a safer location
____Requires Electrical Approval, forward to dboyer@PLANT.MIT.EDU
____Requires Structural Approval, forward to kcollupy@plant.mit.edu,
____Requires MIT Police Dept Approval/ Notification, forward to cp-command@mit.edu
____Obtain a Permit from _____
____Other
Reviewed by (staff person’s name) MIT Safety Program, EH&S Office (N52-496, phone x2-3477, fax x8-6831) (Safety Program will forward this request and copy the exhibitor.)
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Requirements of other departments:
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(When all approvals are completed, exhibitor & professor/ supervisor sign final message.)
EXHIBITOR STATEMENT: I understand the above requirements and will abide by them. I will post the original signed form next to/ on the exhibit. I will mail or fax a hard copy to the space administrator and the MIT Police Dept. I understand it is my responsibility to remove, dispose of and/ or clean up all materials and to pay for any removal/cleaning costs if this is not done immediately after the exhibit.
SIGNATURE & DATE ________________

PROFESSOR/ SUPERVISOR/ SPONSOR STATEMENT: To my knowledge, I certify that the above individual(s) has/have complied with all of the above requirements and conditions. I understand my responsibility to ensure the safety of this exhibit/ project.
SIGNATURE & DATE _________________