Equipment or Services Request Form

Date of Activity or Class

Time of Activity or Class

Location of Activity or Class

Coordinator or Instructor

Activity or class needing equipment or service

Contact person's name & phone number

Do you need Media Services to set this equipment up?
Yes No 
Do you need a Media Services person to run this equipment?
Yes No 

Will you pick this equipment up? Yes No  
When?  

When will you return it?

Please describe the room set-up.

Equipment Required (please check all that you need)

Audio Amplification 
Do you need to play an audio tape? Yes No 

Number and type of Mics needed (vocal, speaking, instrument)

Number of mic stands needed
Do you need to play a CD? Yes No 

SGA Amp                     Audio Recording 
Video Taping                TV/VCR Unit

Video Camera               Tripod 
16mm Film Projector    Slide Projector

Overhead Projector     LCD Projector 
Lap Top Computer

High Tech Cart IBM     
Network Connection

Other Equipment

Other Needs

Other Items (bulbs, batteries, cords, carousels, etc)

Any Additional Information

Your Name

How may we contact you? (phone or e-mail)

Do you need confirmation that your request has been scheduled? Yes No