Please complete all requested information

Requester's Name       
Title                  
School                 
Telephone No.          
Email Address          

Course Information
Name of Teacher        
Name of Course         
Course Number          
Department             
No of Classes/Year      1 2 3 4
Expd. Enrollment/Class 1-10 11-20 21-30 31-50 More than 50

Book Requested          Frankenstein by Mary W. Shelley The Time Machine by H.G. Wells The Lost World by Arthur C. Doyle A Princess of Mars by Edgar R. Burroughs From Earth to the Moon by Jules Verne The Moon Pool by A. Merritt
Please note that books not yet published will be shipped when released

Mailing Information
Name                   
Address Line 1         
Address Line 2         
Address Line 3         
City, State, Zip