Reprographic Office– UW Library
Dobra 56/66, 00-312 Warsaw, Poland
tel.: (+48) 22 55-25-400
e-mail: informacja.buw@uw.edu.pl
Warsaw, .:____-____-20___

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

___________________________________________
Name, Surname

___________________________________________
Library card number/ ID number (ELD / ELP)

___________________________________________
Phone no.

___________________________________________
E-mail address

B. Ordered Materials’ Bibliographic Details . Attention: one person is allowed to request scans of up to 50 pages 
Author	Title	Call number	Year / No. / Pages / Remarks	

				

				
				
C. General Information
The service will be carried out as soon as possible. We reserve the right to send back orders containing incomplete or incorrect personal or bibliographic data. Customer will be asked to verify them.
Only UW students and employees with a valid library (BUW) card are entitled to use the free scanning service.
Please consider your orders carefully. Persons staying in Warsaw are welcome to borrow books on site at the University of Warsaw Library (BUW).
Scanning is carried out into black and white TIFF files or a PDF file at a resolution of 300 to 400 dpi.
D. Legal Information 
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).

To provide the service, you must agree to the processing of your personal data:
E. General Data Protection Regulation (GDPR) Consent Forms
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 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.

Customer’s Signature:

_________________________________

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

		
Date:		
Staff signature: