Fillable Reproduction Order CONDITIONS OF USE FORM MUST BE

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Reproduction Order CONDITIONS OF USE FORM MUST BE

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CONDITIONS OF USE FORM MUST BE SIGNED AND SUBMITTED BEFORE ORDER CAN BE COMPLETED.
COMPLETION OF THIS FORM DOES NOT GRANT PERMISSION TO PUBLISH.
IF YOU WISH TO PUBLISH THESE IMAGES, A PERMISSION TO PUBLISH FORM MUST BE SIGNED.
Reproduction Order
azhs.org | TEMPE (480) 387-5355 | TUCSON (520) 617-1157 | ahsreference@azhs.gov
Reproduction Order
LAA20-004 06/20
Name _____________________________________________________________________________ Date _________________
Company/Institution (if applicable) _________________________________________________________________________
Address _________________________________________________________________________________________________
City/State/ZIP Code _______________________________________________________________________________________
Phone ___________________________________________________ Email _________________________________________
FORMAT OPTIONS
Photocopy
PDF Scan
(100 dpi, black/white scan)
JPEG Scan
(low resolution,150 dpi)
JPEG Scan
(high resolution, 600 dpi)
Special Request, please specify: ____________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
DELIVERY OPTIONS
$5 CD $7 U.S. Mail FREE Email FREE In-person pick up
ITEM NUMBER TITLE/DESCRIPTION UNIT PRICE FEE TOTAL
Subtotal
Delivery
TOTAL
METHOD OF PAYMENT
Cash Check /Check# Corporate Acct. (send invoice)
Credit Card, please call with credit card information. Please do not email this information.
STAFF USE ONLY
Receipt# Date Completed Staff Initials
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Reproduction Order CONDITIONS OF USE FORM MUST BE

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Completed 20 July 2020

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