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* denotes required field
Contact Information
Contact Name *
Contact Mailing Address *
Department *
School *
Contact Phone Number *
Contact Fax Number
Contact Email Address *
User Same as Contact
User Name *
User Phone Number *
User Fax Number
User Email Address *
Account Information
A department account number is only required for items (laptop, projector, lavaliere mic., mp3 recorder). Account number will be charged if the equipment or supplied accessories are lost, broken or stolen. Department’s account number will also be charged for late returns at the discretion of Campus Media.
Account Number
Course Information
Course Number
Course Name
Location
Building
Room
Date(s) and Time(s)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Begin Date
Select Start Date from Calendar
End Date
Select End Date from Calendar
Start Time
Actual Start Time of Class
(e.g. 6:20pm)
End Time
Actual End Time of Class
Classroom Equipment and Services
Audio
Audio Cassette Player
Compact Disc Player
P. A. System with Microphone
MP3 Recorder
Video
Video Recording
Digital Video Camera/Tripod
Video Playback
Video Playback VHS
Video Playback DVD
Foreign Video Playback VHS
Foreign Video Playback DVD
Projection
Document Camera
Overhead Projector (for transparencies)
Data/Video Projector
35mm Slide Projector
Other Projection
Other Services/Personnel
Equipment Demonstration
Mac Adapter
Specify Equipment Demonstration
Mac Model
DVD/VCR Remote
Notes
Special Instructions
