Please complete as much detail as possible:

Request No:

Student Name:                                                                                      Yr. Level:

School:

School Address:

Visiting Teacher:

Date Requested:                             Date Required:

Title:

Author:

Publisher:                                        Place:

Year of Publication:                         Edition:                                            ISBN:

Pages to be Enlarged:                      Cost:                                               Dewey No:

Date Completed:                             Mailed:                                            Held:

Instructions (please tick)

• Post to School (please supply address above)
• Post to Visiting Teacher
• Hold in Resource
• Print size:  N12  N14  N16  N18  N20  N24 (please circle)
• Paper size:  A3  B4  A4
• Binding required:  Yes No
• Book supplied:   Yes No
• Currently on loan to:                                Return requested:

Please indicate the order and date in which chapters are required if possible!

• Chapter Number
• Date Required

Signed by Visiting Teacher:__________________________________Date:_____________________

For Further Information please contact:
Dianne Skillern
Statewide Vision Resource Centre
Phone: 03 9841 0242
Fax:     03 9841 0878
email: diannesk@svrc.vic.edu.au

Top of Page
Home Page