PHOTOCOPY REQUEST FORM
8.5 X 11 @ $0.20 x____ = $_____ 8.5 X 14 @ $0.30 x____ = $_____ 11 X 17 @ $0.40 x____ = $_____ Total $_____
Name: ___________________________________
Address: _________________________________
City/State/Zip: ____________________________
E-Mail:___________________________________
Phone: ___________________________________
Notice: Warning
Concerning Copyright Restrictions The
copyright law of the Under
certain conditions specified in the law, libraries and archives are
authorized to furnish a photocopy or other reproduction. One of these specified conditions is that
the photocopy or reproduction is not to be “used for any purpose other than
private study, scholarship, or research.”
If a user makes a request for, or later uses, a photocopy or
reproduction for purposes in excess of “fair use,” that user may be liable
for copyright infringement. The
institution reserves the right to refuse to accept a
copying order if, in its judgment, fulfillment of the order would
involve violation of copyright law.
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By signing this form I agree to assume all responsibility
for compliance with copyright laws and to hold harmless The University if Name:__________________________________________________
Date:______________ |