Luzerne County Community College
Public Safety Training Institute
Request for Duplication
Must be submitted at least three (3) weeks in advance of “Start Date” to: Barbara Choma, Public Safety
Training Institute, Luzerne County Community College, 1333 S. Prospect St., Nanticoke, PA 18634-3899
Course #: Start Date: Quantity:
Title of Material to be Duplicated:
Please Circle:
Collate: Yes No Back-to-Back Printing: Yes No
Cover: Yes No (Please indicate cover with note)
Staple: Yes No Right Corner Yes No Side (2 staples)Yes No
Tape Bind: Yes No
Paper Color: White Blue Yellow Pink Tan
Cover Color: White Blue Yellow Pink Tan
ALL PAGES MUST BE NUMBERED IN ORDER TO BE SUBMITTED TO OUR DUPLICATING
DEPARTMENT
Special Instructions
Name, address and telephone number of requesting person (UPS mailing – No Post Office Boxes)
Name:
Address:
City, State, Zip:
Telephone Number
Duplication Must Be in Accordance with the Copyright Act of 1976
This form is to be used also when requesting student manuals, etc.
Date Received:
Public Safety-Forms-Request for Duplication (060728)
