archival copy
binding form

graduate liberal studies Program
284 High Street
Middletown, CT  06457
Phone (860) 685-2900
Fax (860) 685-2901

To be submitted to the GLSP office by the student with appropriate fees and archival quality copies of the essay/project.
 
Student Information
___ ___ ___ ___ ___ ___  
WesID# Name: first, middle, last        
           
Home address City   State   ZIP
           
Home phone Work phone   Preferred e-mail  
 
copy information


______ Number of copies submitted for binding      X      $20    =      $_________    total
 

*Students are strongly encouraged to order one bound copy for their own use/record in addition to the one required copy for Olin Library archives, for a total of 2 bound copies
 
_____ I will pick up bound copies at the GLSP office.  Please notify me via email when copies are ready.
_____
I will pick up my copies at the GLSP Champagne Reception held during commencement.
_____
Please mail my copies to the above address. 
Payment
Amount to charge: $__________   Visa  MasterCard Check payable to Wesleyan University  
     
__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Charge Card Number

__ __ / 20__ __
 Exp Date

 _________________________________
 Student Signature

Office Use Only
Amount received: ___________ Credit Card Check Check#: ___________ Date: _____________

 
Term _____________________ 
_____ Copies sent to be bound on _____________________  (date)
_____ Number of bound copies returned to office and student notified on ____________________  (date)
_____

Picked up by student     OR     _____ mailed to student (at above address),  ____________________  (date)
_____ Student will pick up at the GLSP Champagne Reception