Form NRC Form 171 NRC Form 171 Duplication Request

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 171
(11-2006)

APPROVED BY OMB: NO. 3150-0066

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this information request to obtain
a benefit: 8 minutes. This information is needed to locate the document(s)
requested by the individual. Send comments regarding burden estimate to the
Records and FOIA/Privacy Services Branch (T-5 F52), U.S. Nuclear Regulatory
Commission, Washington, DC 20555-0001, or by internet e-mail to
infocollects@nrc.gov, and to the Desk Officer, Office of Information and
Regulatory Affairs, NEOB-10202, (3150-0066), Office of Management and
Budget, Washington, DC 20503. If a means used to impose an information
collection does not display a currently valid OMB control number, the NRC may
not conduct or sponsor, and a person is not required to respond to, the
information collection.

DUPLICATION REQUEST

REQUEST NUMBER

DATE OF REQUEST

DOCUMENT FILE INFORMATION
OUTPUT CATEGORIES:

P
C

PAPER
CASSETTE

CD CD ROM
D
DISKETTE

AF APERTURE FULL BLOWBACK
AR APERTURE REDUCED BLOWBACK

M MICROFORM
AD APERTURE DUPLICATE

Some items must be done in the same format (example, audio cassette). Consult staff or price list regarding available formats.
NO. OF
COPIES

IDENTIFICATION

OUTPUT
CATEGORY

OUTPUT
CATEGORY

SEND TO (if different from BILL TO)

BILL TO
ORGANIZATION

ORGANIZATION

NAME

NAME

ADDRESS

ADDRESS

CITY, STATE, ZIP CODE

CITY, STATE, ZIP CODE

TELEPHONE (Include Area Code/Ext)

NO. OF
COPIES

IDENTIFICATION

FAX TELEPHONE (Include Area Code/Ext)

TELEPHONE (Include Area Code/Ext)

FAX TELEPHONE (Include Area Code/Ext)

PICKUP
HOLD FOR PAYMENT UPON PICKUP

COPY SERVICE ACCOUNT NO.

OTHER (Specify)

INVOICE

CUSTOMER PURCHASE ORDER NO.

EXPRESS MAIL OPTION ACCT NO. (if applicable)

MAIL
CREDIT CARD NUMBER

CREDIT CARD:
ORDERED

VISA
COMPLETED

NRC FORM 171 (11-2006)

MASTER CARD

EXPIRATION DATE

DISCOVER

SPECIAL INSTRUCTIONS

PRINTED ON RECYCLED PAPER