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Dept. & Course No: _________________________          Course URL: __________________________________

Instructor: ________________________________          E-Mail Address: ________________________________

                                    Fill Out Completely - Type or Print Legibly
                                                                                   # of    Loan    E-Item     Status
                                                                                   Cops   Period
  CALL NUMBER            AUTHOR/EDITOR                 TITLE/EDITION




Semester:      ________ Fall                Spring      ________ Summer            Year: ________

Loan Period:     Room          Overnight      1Day         2Day        3Day        7Day

                                           Office Use Only/Proc. Complt: _________ Date Complt: _________ List# _______