1. E-mail address:

2. Your Name:

3. Name of the company or institution you represent:

4. Title of the Virtual Hospital book from which you are requesting material:

5. URLs of the pages that contain the content you wish to use:

6. Your intended use of the material (Click on all that apply):
a printout to be used for classroom instruction
a printed publication to be sold
as part of a printed academic textbook or journal
as part of a CD-ROM
as part of an electronic slide show
as part of a Web site
as part of an Intranet site
as part of a news or feature article that will appear in print or broadcast form
Other:

7. Please add to the description of your choice in item #6:

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