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pdfNRC FORM 171
(MM-YYYY)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0066 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 Information 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, DATE OF REQUEST
(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
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
NO. OF
COPIES
IDENTIFICATION
BILL TO
SEND TO (if different from 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 PDR
PICKUP AT COPY SERVICE
EMAIL
MAIL (U.S. POSTAL SERVICE)
FAX
UPS (UNITED PARCEL SERVICE)
FEDERAL EXPRESS
COPY ACCOUNT ON FILE
SHIPPING OPTION ACCT. NO. (If applicable)
OTHER (Specify)
OTHER:
VISA
MASTER CARD
DISCOVER
AMERICAN EXPRESS
ORDERED BY
(INITIALS)
NRC FORM 171 (MM-YYYY)
COMPLETED BY
(INITIALS)
CREDIT CARD NUMBER (Include Hyphens -)
EXPIRATION DATE
AMEX CARD NUMBER (Include Hyphens -)
EXPIRATION DATE
SPECIAL INSTRUCTIONS
REPRODUCTION CONTRACTOR
NRC FORM 171
(MM-YYYY)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0066 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 Information 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, DATE OF REQUEST
(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
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
NO. OF
COPIES
IDENTIFICATION
BILL TO
SEND TO (if different from 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 PDR
PICKUP AT COPY SERVICE
EMAIL
MAIL (U.S. POSTAL SERVICE)
FAX
UPS (UNITED PARCEL SERVICE)
FEDERAL EXPRESS
COPY ACCOUNT ON FILE
SHIPPING OPTION ACCT. NO. (If applicable)
OTHER (Specify)
OTHER:
VISA
MASTER CARD
DISCOVER
AMERICAN EXPRESS
ORDERED BY
(INITIALS)
NRC FORM 171 (MM-YYYY)
COMPLETED BY
(INITIALS)
CREDIT CARD NUMBER (Include Hyphens -)
EXPIRATION DATE
AMEX CARD NUMBER (Include Hyphens -)
EXPIRATION DATE
SPECIAL INSTRUCTIONS
RECIPIENT
NRC FORM 171
(MM-YYYY)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0066 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 Information 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, DATE OF REQUEST
(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
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
NO. OF
COPIES
IDENTIFICATION
BILL TO
SEND TO (if different from 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 PDR
PICKUP AT COPY SERVICE
EMAIL
MAIL (U.S. POSTAL SERVICE)
COPY ACCOUNT ON FILE
SHIPPING OPTION ACCT. NO. (If applicable)
UPS (UNITED PARCEL SERVICE)
FAX
FEDERAL EXPRESS
OTHER (Specify)
OTHER:
VISA
MASTER CARD
DISCOVER
AMERICAN EXPRESS
ORDERED BY
(INITIALS)
NRC FORM 171 (MM-YYYY)
COMPLETED BY
(INITIALS)
CREDIT CARD NUMBER (Include Hyphens -)
EXPIRATION DATE
AMEX CARD NUMBER (Include Hyphens -)
EXPIRATION DATE
SPECIAL INSTRUCTIONS
PDR STAFF
| File Type | application/pdf |
| File Title | c:\informs\fixforms\nrc171_7.wpf |
| Author | DAHersey |
| File Modified | 2012-06-08 |
| File Created | 2011-09-06 |