1. I [ ] of [ ] hereby request you to make and supply to me *[a copy of (particulars of article)] *[a copy of (particulars of work of which a part is required to be supplied and particulars of that part)], which I require for the purposes of research or private study.
2. I have not previously been supplied with a copy of *[the said article] *[the said part of the said work] by any librarian.
3. I undertake that if a copy is supplied to me in compliance with the request made above, I will not use it except for the purposes of research or private study.