Instructor: ___________________________________                          Date Required: _______________________________

 

Department:  _________________________________                           Campus Phone:  ______________________________ 

 

Campus:  ____________________________________                           Home Phone:  ________________________________

 

Alternate Contact: _____________________________                           Alternate Contact Phone:  ______________________

 

 

Course Name:  ______________________________________________________________________________________ 

 

Course Number & Section:  ____________________________________________________________________________  

 

Sets Required:  _______________________________                            Original Pages: _____________________________

 

Desk Copies Required: _________________________                            Original Pages:   Single-Sided    Double-sided     

 

Total Needed:  ____________________________

 

 Paper color:  ______________________________                         

 

Cover color:  ______________________________                                  GBC Binding:  _______________________________

 

Insert Page/Color:  _________________________                                    3HD/Shrink Wrap ____________________________ 

 

Tabs:  ___________________________________                                  Other:  ____________________________________

 

Print Single-Sided:                                     Print Double-sided: 

                     Check if want Originals returned and to whom/location _______________________________________

                           _________________________________________________________________________________ 

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Special Instructions:  __________________________________________________________________________ 

 

___________________________________________________________________________________________

 

___________________________________________________________________________________________

 

 

______________________________________                       ___________________________________________

Department Head/Date                                                                       Instructor’s  Signature/Date