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Instructional Request Form

PLEASE NOTE: an asterisk(*) indicates required information

Requestor's Information

Honorific *

First Name *

Last Name *

Address 1 *

Address 2  

Address 3   

City *

State/Province *

Postal Code *

Country *

Phone   

Fax   

E-Mail   



Educational Institution

Requestor's Name *

Institution *

  *



Material Requested From Our Work

Harcourt Publishing Division   

Series Title *

Component Title  

Edition   

Volume   

Number   

ISBN   

Grade or Level   

Author or Editor *


Have your students purchased our related textbook? Yes  No 
Has the requestor used the same material previously? Yes  No 
  If so, please provide us with the REQUEST ID number or reference of the previous use.
 

 

Describe the exact material you are using including opening and closing page numbers, figure numbers and titles of selections from our work. A selection could be a poem, chapter, essay, introduction, etc. from our work. *

 

Number of copies you will make *



Web Publishing

If our material is going to be posted on a website...
What is your web address?
Is your site password protected? Yes   No

Estimated date our work will appear on your site

 

Additional Comments

 


 




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