Coursepack Request Form

Date of Request:
Start of Term:
University:
Course Name:
Course #:
Instructor:
Email:

CCC Acct # (if applicable)

100-3042-410
Organization:
Middlebury College Store
Contact:
Georgia Best
Address 1:
The College Store
Address 2:
58 Hepburn Rd.
City/State/Zip:
Middlebury, VT 05753
Tel:
802-443-2258
Fax #:
802-443-2062
No of Sets:

Mo: Day:
Yr.
Mo: Day:
Yr:
Middlebury College

Photocopy permission is requested for the following works for ONE-TERM use in educational course sets:

Each item with a black box ( * ) must be completed.

Please Type or Print Legibly

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ISBN/ISSN:

Out of Print Work? Y / N

Add'l Info Attached? Y / N

*Auth/Ed/Trans of Book:

*Publisher/Rightsholder:
* Book/Joumal Title:
Chapter/Article Name:
*Author of Chapter/Article:
*Copyright Year (2 digits):

Your Line Item Ref #:

ISBN/ISSN:

*Total # of Pgs.:
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Out of Print Work? Y / N

*From:
Volume:

*To:
Edition:

Add'l Info Attached? Y / N

*Auth/Ed/Trans of Book:

*Publisher/Rightsholder:
* Book/Joumal Title:
Chapter/Article Name:
*Author of Chapter/Article:
*Copyright Year (2 digits):

*Total # of Pgs.:
Pub'n Yr (If Differs):

*From:
Volume:

*To:
Edition:

Your Line Item Ref #:

ISBN/ISSN:

Out of Print Work? Y / N

Add'l Info Attached? Y / N

*Auth/Ed/Trans of Book:

*Publisher/Rightsholder:
* Book/Joumal Title:
Chapter/Article Name:
*Author of Chapter/Article:
*Copyright Year (2 digits):

Your Line Item Ref #:

ISBN/ISSN:

*Total # of Pgs.:
Pub'n Yr (If Differs):

Out of Print Work? Y / N

*From:
Volume:

*To:
Edition:

Add'l Info Attached? Y / N

*Auth/Ed/Trans of Book:

*Publisher/Rightsholder:
* Book/Joumal Title:
Chapter/Article Name:
*Author of Chapter/Article:
*Copyright Year (2 digits):

Your Line Item Ref #:

ISBN/ISSN:

*Total # of Pgs.:
Pub'n Yr (If Differs):

Out of Print Work? Y / N

*From:
Volume:

*To:
Edition:

Add'l Info Attached? Y / N

*Auth/Ed/Trans of Book:

*Publisher/Rightsholder:
* Book/Joumal Title:
Chapter/Article Name:
*Author of Chapter/Article:
*Copyright Year (2 digits):

*Total # of Pgs.:
Pub'n Yr (If Differs):

*From:
Volume:

Did you complete each item identified with a black box (*) ?

*To:
Edition: