Reprographic Office – UW Library
Dobra 56/66, 00-312 Warsaw, Poland
tel.: (+48) 22 55-25-400
e-mail: reprobuw@uw.edu.pl

Warsaw:____-____-20___

A. Customer Details (all fields must be filled in)

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Name, Surname

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Address

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___________________________________________
Phone no.

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E-mail address

B. Ordered Materials’ Bibliographic Details 
Author	Title	Call number	Year/No./Pages/Remarks	

				

				
				
C. Type of Service (mark in the appropriate box)
1.	Type of reproduction	Scanning	or	Xero copy	
2.	Format	JPEG	TIFF		A4	A3	
		
3.	Quality	black & white	grayscale	color	
4.	Number of pages	1 page per copy/scan	2 pages per copy/scan	
		
5.	Method of payment	bank transfer	invoice*	pro-forma invoice*	IFLA voucher 	
6.	Method of delivery	network transfer or e-mail	by post	personal pickup	
	
7.	Customer’s additional remarks		
		
8.	Library’s remarks		
* In case you wish to an invoice, please fill in an additional form.

D. Legal Information 
Due date should be consulted with the Reprographic Office (standard due date – up to two weeks). Service implementation starts after receiving the form and payment.
The University of Warsaw Library does not take responsibility for copyright violation made by the Customer. The University of Warsaw Library does not give permission and does not take responsibility for further use of reproduced materials that come from the Library collections and are protected by the Law on Copyright and Related Rights (Pl. Ustawa o prawie autorskim i prawach pokrewnych z dnia 4 lutego 1994 r. – Dz. U. 1994 nr 24 poz. 83).  
E. General Data Protection Regulation (GDPR) Consent Forms
I was informed that:
1.	The administrator of my personal data is the University of Warsaw, represented by the Rector, with headquarters at Krakowskie Przedmieście 26/28, 00-927 Warsaw, Poland. 
2.	You can contact the administrator of personal data at e-mail address: iod@adm.uw.edu.pl
3.	Your personal data given in this form will be processed in order to implement reproduction service, particularly to:
•	agree on details of the service implementation;
•	proceed with the payment;
•	proceed with the shipment.
4.	The data will be processed for the duration of the service implementation only. 
5.	Data will be proceeded according to the Privacy Policy.
6.	Providing data is voluntary, however it is necessary for achieving the service implementation. 
F. Final Statements (mark X in the appropriate box):
1.	[ ] YES [ ] NO I have read the GDPR information, including the information about the aim and way of personal data proceeding and about the right to access and correct my data. 
2.	[ ] YES [ ] NO I give my consent to the processing of personal data in order to the implementation of reprographic service.
3.	[ ] YES [ ] NO I give my personal data on a voluntary basis and I declare that they are truthful.
4.	[ ] YES [ ] NO I undertake to pay the ammount calculated according to the List of University of Warsaw Library Fees (in Polish only, Table 2 presents the reprography fees).
Customer’s Signature:

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G. Settlement (to be filled in by the Reprographic Office) 
t the ReReprographic Office)	
Quantitative:		Financial:	

			
Date:		Total:	
Staff signature:			
			
H. Receipt			
Date:		Signature: