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  1.                        Reprint Order Form
  2.  
  3. Please send to:
  4.         Name_______________________________
  5.  
  6.         Address____________________________
  7.  
  8.         ___________________________________
  9.  
  10.  
  11. Copies requested:
  12.  
  13.     Volume #      |     Page #    |    # of Pages
  14.         ______________|_________________|___________________
  15.                       |                 |
  16.         ______________|_________________|___________________
  17.                       |                 |   
  18.         ______________|_________________|___________________
  19.                       |                 |
  20.         ______________|_________________|___________________
  21.                       |                 |
  22.         ______________|_________________|___________________
  23.                       |                 |
  24.         ______________|_________________|___________________
  25.  
  26.                               Total # of pages _____________
  27.                               Cost per page __________X  .25
  28.  
  29.                               Sub-total_____________________
  30.                               Add handling and shipping_2.50
  31.  
  32.                               Total_________________________
  33.  
  34. ___ Money order enclosed
  35.  
  36. ___ MC ___VISA #____________________________ Expires________
  37.  
  38.  
  39.  
  40.                         STATEMENT OF USE
  41.  
  42.           I hereby certify that any reprints that I order from 
  43. R. L. Hack, will be used for private study or research by my-
  44. self, as intended by Sec. 2(a) of the Copyright Act of Canada.
  45. R. S. c55, s.1.
  46.  
  47.           Furthermore, should I violate the Copyright Act, I
  48. will indemnify R. L. Hack.
  49.  
  50.  
  51.  
  52. Signed_____________________________
  53.  
  54. Date_______________________________