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AV Equipment Request Form

ROOM # HOUR TO BE PICKED UP __________________

NAME EXT #

FILM TITLE_________________________________ #________________

__16 mm PROJ   __SLIDE PROJ/REMOTE   __FILMSTRIP/PROJ

__SCREEN   __SLIDE/CASSTAPE   __FILMS  TRIP/CASSTAPE

__TAKE UP REEL   __SLIDE VIEWER   __OVERHEAD PROJ

__EXT SPEAKER   __EMPTY TRAY   __OPAQUE PROJ

__CASS RECORDER   __MICROPHONE    OTHER ________

__BLANK CASS   __STAND CORD

ORDER TAKEN BY _____________  EQUIPMENT #_____________________

EQUIP DELIVERED BY _______________ EQUIP RETURNED BY ___________

SPECIAL INSTRUCTIONS______________________________________________________

__________________________________________________________________________

OTHER_____________________________________________________________________