Equipment Request

Type of Equipment Requested

Date and Time of Pickup

Date: 
Time:

Date and Time of Use

Date:
Time:

Date and Time of Return

Date:
Time:
Media Assistance is determined on a case-by-case basis

Your Name

Your E-mail

Your Phone Number


Please leave a number that can be reached during the day

Status

Usage

Please state the use so that we can assist you in the best way possible.

Submit

By submitting this form, I agree to assume responsibility for this equipment from the time I pick it up, 
until it is returned to the Instructional Media Center.

You will receive an e-mail confirmation from the Instructional Media Center as to whether or not the equipment you requested is available.