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Document Delivery payment authorisation

I, the undersigned, authorise Document Delivery Services to obtain the requested materials. I guarantee to reimburse the Library with all costs associated with the request(s).

Date: ___/___/___

Name: ______________________________

Signature: ______________________________

Address: __________________________________________________________________

Contact No.: (work) _________________ (home) _________________

ID Number: ______________________________

Departmental Account No: __ __ __ __ __ __ __ __ __ __ __ __ __ 

Note: if no departmental account number is given, the individual named above will be invoiced for reimbursement of costs.

Departmental Authorisation for the Account Number listed above:

Name: ________________________________________

Signature: _____________________________________

Item details

Author: ______________________

Title: ________________________

Office Use

Other (please specify):

Total Cost:

Item received: ____________________________________________