SUPPLIES & RESOURCES RESERVATION

If you have any questions, please contact Lindsey Kline at 531-0003 ext. 320032 or email at lkline6@pennstatehealth.psu.edu.

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* 1. First and Last Name

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* 2. Email Address

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* 3. Phone Number

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* 4. Your role/position at the medical school (e.g. 1st year medical student, 4th year nursing student, assistant professor, etc)

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* 5. MEDICAL SUPPLIES: Please indicate which items you wish to reserve. The number in parenthesis indicates the quantity available.

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* 6. How long would you like to reserve this item/these items?

Date
Date

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* 7. Comments: Indicate the intended purpose of the item(s).

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* 8. How long would you like to reserve this item/these items?

Date
Date

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* 9. Comments: Indicate the intended purpose of the item(s).

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* 10. OFFICE SUPPLIES: Please indicate which items you wish to reserve. The number in parenthesis indicates the quantity available.

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* 11. How long would you like to reserve this item/these items?

Date
Date

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* 12. Comments: Indicate the intended purpose of the item(s).

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* 13. LITERATURE: Please indicate which items you wish to reserve. The number in parenthesis indicates the quantity available.

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* 14. How long would you like to reserve this item/these items?

Date
Date

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* 15. Comments: Indicate the intended purpose of the item(s).

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* 16. DVDs: Please indicate which items you wish to reserve. The number in parenthesis indicates the quanity available.

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* 17. How long would you like to reserve this item/these items?

Date
Date

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* 18. Comments: Indicate the intended purpose of the item(s).

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* 19. CD-ROMs: Please indicate which items you wish to reserve. The number in parenthesis indicates the quantity available.

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* 20. How long would you like to reserve this item/these items?

Date
Date

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* 21. Comments: Indicate the intended purpose of the item(s).

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