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  Note:  Please provide as much information as possible to help identify the specific item that you are seeking.  You must fill out a separate form for each item you request.
  

  Name: (Last, First):	*
  Email Address:	*
  Status:	*	- Select - MUSM Student Faculty Staff
  Department/Program:	*
  Article Delivery Options:	*	- Select - Pick up at Library Email chapter/pages Mail chapter/pages (MUST INCLUDE ADDRESS) Fax chapter/pages (MUST PROVIDE FAX NUMBER)
  Mailing Address:
  Fax Number:
  Would you like articles ordered on Interlibrary Loan (ILL) if the library does not own them? (Minimum three dollar/item charge to your department) Please allow up to 10 days for receipt.	*	- Select - Yes No
  Item not needed after:
  Book Title:
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  Edition:
  New Edition if Available:		- Select - Yes No
  Publisher:
  Year published:
  Inclusive Pages (if applicable):
  OR Chapter Name/Number:
  Comments: