CD-0053
(Revised 7/2013)
UNCW Printing Services
Course Pack Request Form
Course Pack No._____________
COURSE INFORMATION
(Printing Services use only)
Course Title___________________________________________________________________________
Course #__________________________________ Semester ___________________________________
Instructor ________________________________ Department _________________________________
Campus Phone _______________________ Email Address ____________________________________
Alternate Contact ____________________Email Address____________________ Phone ___________
COPY INSTRUCTIONS
No. of Students Registered for this Course __________
Total Desk Copies Requested __________
(1 courtesy copy provided for every 25 course packs ordered)
Cover Choices:
□ white
□ blue
□ cherry
□ ivory
□ salmon
□ canary
□ other ____________
□ buff
□ gray
□ green
Binding Choices:
□ comb binding
□ tape binding
□ dual staple
□ coil binding
□ 3 hole drill
□ other __________
Printing Options:
□ single-sided □ double-sided
□ specific instructions _____________________________________________
Special Instructions: ___________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Exact Repeat of __________Semester | Repeat w/changes of _________ Semester | New Course Pack _________
COPYRIGHT INFORMATION
Is there copyrighted material in this packet? □ YES □ NO | If yes, who is securing permission to copy?
□ Professor / Department (Attach a copy of documentation for each book or article)
□ UNCW Printing Services (Complete 2nd side of this page / Copy 2nd side for additional space)
I request that UNCW Printing Services produce the above outlined course pack for the above referenced course. I have listed all
copyrighted materials on the attached pages that will be reproduced for this course pack (or have attached a copy of documentation
for permissions.) All additional material is my original work or items classified as “Public Domain”. I understand that only the
work that receives copyright clearance will be included in this course pack. If copyright clearance cannot be obtained for any
particular book or article, I will be notified.
Authorized Signature __________________________________________ Date _________________________
Course Packs can be submitted, along with this Course Pack Form by:
1. Email (preferred) to printingservices@uncw.edu
2. Hard Copy thru Campus Mail or brought by Printing Services on Sawtooth Drive
Questions or Concerns: UNCW Printing Services | Lola Reid | reidl@uncw.edu | Phone 962.3084 | Fax 962.7118
INFORMATION FOR COPYRIGHTED BOOKS / ARTICLES IN THIS COURSE PACK
(Please type or print legibly / Circle choices)
Page ___ of ___
ISBN / ISSN: ___________________ Author / Editor /Translator: _________________________________
Publisher / Rightsholder: __________________________________________________________________
Book / Journal Title: _____________________________________________________________________
Chapter / Article Name: ___________________________________________________________________
Author of Article: ___________________________ Total # of Pages: _______ From: _______ To: _______
Copyright Year: _______________ Publisher Year: ______________ Volume: ________ Edition: ________
Printing Services Use Only: CCC __________ Direct __________ Response _______________________
ISBN / ISSN: ___________________ Author / Editor /Translator: _________________________________
Publisher / Rightsholder: __________________________________________________________________
Book / Journal Title: _____________________________________________________________________
Chapter / Article Name: ___________________________________________________________________
Author of Article: ___________________________ Total # of Pages: _______ From: _______ To: _______
Copyright Year: _______________ Publisher Year: ______________ Volume: ________ Edition: ________
Printing Services Use Only: CCC __________ Direct __________ Response _______________________
ISBN / ISSN: ___________________ Author / Editor /Translator: _________________________________
Publisher / Rightsholder: __________________________________________________________________
Book / Journal Title: _____________________________________________________________________
Chapter / Article Name: ___________________________________________________________________
Author of Article: ___________________________ Total # of Pages: _______ From: _______ To: _______
Copyright Year: _______________ Publisher Year: ______________ Volume: ________ Edition: ________
Printing Services Use Only: CCC __________ Direct __________ Response _______________________
ISBN / ISSN: ___________________ Author / Editor /Translator: _________________________________
Publisher / Rightsholder: __________________________________________________________________
Book / Journal Title: _____________________________________________________________________
Chapter / Article Name: ___________________________________________________________________
Author of Article: ___________________________ Total # of Pages: _______ From: _______ To: _______
Copyright Year: _______________ Publisher Year: ______________ Volume: ________ Edition: ________
Printing Services Use Only: CCC __________ Direct __________ Response _______________________