Date:

Library:

Request for: Loan Photocopy

Book: Author(Last name, First name) OR Serial: Title, Volume, Issue, Date:

Book: Title, Publisher OR Article: Author, Title:

Pub. Date/Ed:

Price(if in print):

This ed. only

Pages (for copy):

Required for copies: CCG CCL

Not wanted after (date):

Maxcost($ willing to pay if referral out of area needed):

LC#

ISBN/ISSN:

Verified in:

Notes:

Borrower:

Tel. #:

Borrower's card #:

Library staff initials/date:

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