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U.S. Department of Health and Human Services

Training and Continuing Education

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Audio/Visual Request Form

Audio/Visual Request Form

Updated: 11/10/2003

 

Name __________________________________________________________
         Last                                         First                                       (initial)

E-Mail Address ___________________________________________

Telephone Number _____________________________

Organization _____________________________________________

Ground Shipping Address ___________________________________
(FedEx or UPS - No POB Accepted)

_______________________________________________________

_______________________________________________________

Street Address (if different from mailing address - for UPS and FedEx)

_______________________________________________________

_______________________________________________________
City                                                                 State

Use a separate sheet for each month's request

Catalog NumberTitleDate DesiredAlternate Date
 
 		  
 
 		  
 
 		  
 
 		  
 
 		  

 

Mail to:
ORA Lending LIbrary
Division of Human Resource Development
Food and Drug Administration
5600 Fishers Lane, HFC-60

Fax to:
Lending Library
Katelyn Poss
301-827-9294
                                                             
I have read the policies and procedures for borrowing training materials from the DHRD Library.  I agree to all the terms and conditions therein.

________________________________
signature

 


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