URI SERIAL REQUEST FORM

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TITLE:

PUBLISHER & ADDRESS:

ISSN: ____________________ OCLC #: __________________ FREQUENCY: __________________

PRICE: ______________________ TO BEGIN (vol/yr)_______________

REQUESTED BY: _____________________________________ DATE: ______________________

EVALUATION:

COLLECTION MGT. OFFICER:___________________________________ DATE: _______________

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URI CALL NO. & HOLDINGS (if any):

FUND CODE (HEGIS): ________________ III ORDER RECORD # (ILS#): ______________________

VENDOR: __________________________ VENDOR TITLE #: ________________________________

TO BEGIN: ________________________ BACK VOLS (if any): _____________________________

DATE ORDERED: ______________________ ORDERED BY: ________________________________

12/3/99 rev.