Form NRC Form 171 NRC Form 171 Duplication Requesy

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 FOIA, Privacy, and
Information Collections 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, DATE OF REQUEST
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.

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 FOIA, Privacy, and
Information Collections 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, DATE OF REQUEST
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.

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 FOIA, Privacy, and
Information Collections 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, DATE OF REQUEST
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.

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