| Your Name: |
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| Daytime Phone: |
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| Email Address: |
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| LAST 4 digits of your AID or SSN: |
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| Campus (Please check one): |
Camden
New Brunswick
Newark
Piscataway
Stratford
Distance Learning/WebCT |
| Status (Please check one): |
Faculty
Staff
Student
Resident
Fellow
Other |
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| Which resource were you unable to access? |
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| From where did you attempt to access it? |
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| If Other, please specify: |
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| The problem URL/address: |
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| Error message received |
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| Please describe the problem in your own words: |
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| Which web browser are you using? |
Internet Explorer
Netscape
Firefox
Safari
OTHER |
| If Other, please specify: |
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| on a: |
PC
MACINTOSH |
| What type of connection are you using? |
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| Additional Comments |
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