UMI DISSERTATION EXPRESS ORDER FORM

DATE: ________________________________

YOUR NAME: _______________________  PHONE: _____________________

MAILING ADDRESS OR FULL DEPARTMENTAL ADDRESS:                  
__________________________________________________________________
__________________________________________________________________

E-MAIL ADDRESS: ________________________________________________
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(__) Prepayment required. 
               Make check payable to OLD DOMINION UNIVERSITY LIBRARY

DISSERTATION/THESIS TITLE: _________________________________________

____________________________________________________________________

AUTHOR: __________________________________________________________

UMI ORDER# (if known): ___________________

PAYMENT METHOD (check one):

(__) I will pay $______ for this material.

(__) Charge $ _______to my department/grant number:___________________

     Authorized disbursing signature: ________________________________
     Date: ______________

     Your signature:______________________________ Date: ______________

*****Materials cannot be returned and orders cannot be cancelled.*****
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OFFICE USE ONLY

Payment rec'd/authorized date: __________  Forwarded to LBO: _________

UMI order date (initials): ______  Rec'd date: ______UMI updated: _________

Patron notification date: ________

(Phone): _______________

(E-mail): ________________________

Additional action/comments:___________________________________________