First name:
      Last name:
      Status Faculty/GTA    Graduate Student
      Department:
      Email address:      *
      Phone:
      Please select preference
      by which to be contacted:

      Location of equipment use: Haley Center Room
      Date Needed:   
      Day of the Week M    T    W    H    F
      Preferred Check-out time:   
      Preferred Return time:


      EQUIPMENT QUANTITY
      Multimedia Cart
      DVD/VHS unit
      Overhead Projector
      VHS Video Camera
      CD Player
      Slide Projector
      Other

      ACCESSORIES QUANTITY
      Carousel Tray
      Cart
      Screen
      Tripod
      Other


      PURPOSE of USE


      You will be contacted with a confirmation notice prior to pick-up time.