The New York Academy of Medicine: Library: Document Request Form

Document Request Form

THE NEW YORK ACADEMY OF MEDICINE
1216 Fifth Avenue, New York, New York 10029-5293 TEL: (212) 822-7321 FAX: (212) 423-0266

Division of Information Management
Document Delivery Department

Document Request Form

Please complete the following form and fax it to (212) 722-7650, or mail it to:

The New York Academy of Medicine
Library
1216 Fifth Avenue
New York, NY 10029-5293

Contact Information

Name _________________________________________________________

Address _______________________________________________________

City __________________State _______________ Zip Code ____________

Telephone _______________________ Fax__________________________

Payment Information

Credit Card # ___________________________________ Exp ___________

Name on Card __________________________________________________

Delivery Schedule and Fees

(*Not guaranteed)

Delivery Information

Please check off your preferred method of delivery.

[ ] Fax/Email Please provide fax/email for delivery. ____________________

[ ] FedEx Your Acct. # _________________

[ ] Mail

Shipping Address (if different from above)

Name __________________________________________________________

Address ________________________________________________________

City __________________State _______________ Zip Code _____________

ATTN: _________________________________________________________

Items
You may only request up to ten (10) items per order from the Academy Library. You may only have one(1) order in process at a time.

Item 1