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Please
print and fill out the following form.
Send form to:
University of Illinois Library
Attn: Susan Edwards
1408 W. Gregory Drive
Urbana, IL 61801 USA
The Leopoldo
Cicognara Library Collection on Microfiche
Subscription
Information:
Cost: $42,000.00 USD
Payment Options (check one):
_____ One time payment of $42,000
_____ Two payments of $21,000* (paid over two years or less)
_____ Three payments of $14,000* (paid over three years or less)
*Microfiche collection will be shipped in two or three sections if a payment
plan is used.
Method of Payment:
(Indicate preference)
_____ Check
_____ Wire Transfer
_____ Credit Card (MasterCard or Visa only)
An invoice will be sent to you once we receive your subscription request.
Subscriber Information
Name of Institution:
______________________________________________________________
Contact Name:
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Billing Address:
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City: _________________________________ State: __________ Zip code:
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Country:________________________________ Postal Code:
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Telephone: __________________________ FAX: _____________________________
SHIPPING ADDRESS FOR MICROFICHE (if not the same as above):
Name of Institution:
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Contact Name:
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Street Address: ___________________________________________________Office/Room
# ________
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