Form NRC Form 171 NRC Form 171 NRC form 171 - Duplication Request

NRC FORM 171

U.S. NUCLEAR REGULATORY COMMISSION

(M-YYYY)

DUPLICATION REQUEST

EXPIRES: MM/DD/YYYY

REQUEST NUMBER

Estimated burden per response to comply with this information request to obtain
a benefit: 5 minutes. This data is needed to locate the information requested by
the individual. Send comments regarding burden estimate to the Records and
FOIA/Privacy Services Branch (T-5 F53), U.S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by internet e-mail to
infocollects.resource@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.

DATE OF REQUEST

APPROVED BY OMB: NO. 3150-0066

DOCUMENT FILE INFORMATION
OUTPUT CATEGORIES:
P

PAPER

CD

CD ROM

AF

APERTURE FULL BLOWBACK

DVD

DVD ROM

M

MICROFICHE

AD

APERTURE DUPLICATE

AR

APERTURE REDUCED BLOWBACK

PDF

PDF FILE

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

IDENTIFICATION

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)

OUTPUT
CATEGORY

FAX TELEPHONE (Include Area Code/Ext)

TELEPHONE (Include Area Code/Ext)

FAX TELEPHONE (Include Area Code/Ext)

CUSTOMER EMAIL ADDRESS

SHIPPING METHODS
PICKUP AT COPY SERVICES

PICKUP AT PDR

HOLD FOR PAYMENT UPON PICKUP

SHIPPING OPTION ACCT. NO. (If applicable)

INVOICE

MAIL (U.S. POSTAL SERVICE)

FACSIMILE

UPS (UNITED PARCEL SERVICE)

FEDERAL EXPRESS

COPY ACCOUNT ON FILE

OTHER (Specify)

OTHER:
CREDIT CARD NUMBER

VISA

MASTER CARD

ORDERED BY
(INITIALS)

NRC FORM 171 (M-YYYY)

COMPLETED BY
(INITIALS)

DISCOVER

EXPIRATION DATE

AMERICAN EXPRESS

SPECIAL INSTRUCTIONS

PRINTED ON RECYCLED PAPER