Middle Cities Workers' Compensation Fund
A New Approach

Video Library Order Form

Please provide the following information:

District:
Name:
Address:
City:
State:
Zip Code:
Telephone:
E-mail:
     Please refer to the library listing and enter the item code(s) 
for each video you wish to borrow. You may request as
many videos as you wish, however a maximum
of two videos are loaned out at one time.
Please prioritize your choices.
       Code #1       Code #2    
   Code #3      Code #4

To complete your order, click on the "submit form" button below.

By submitting this form, you agree to return all
videos within 30 days.