*Event:
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*Event location:
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Date and time of event
*From:
Will occur once
Will be repeated
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*To:
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| If your event is to be repeated on several specific dates, please fill in the appropriate blanks below or email a list of dates and times: |
| From:
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To:
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| From:
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To:
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| From:
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To:
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*Please provide a brief description of the event and how the equipment will be used at the event:
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| EQUIPMENT AND ACCESORY NEEDS |
| What do you want to do? (Check all that apply and answer the questions that follow your selection) |
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Play music, a speech or another audio source |
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Audio cassette |
CD |
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Play record |
MP3 |
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Other
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Give a speech, sing or talk to a group using a microphone |
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Wired, on mic stands Quantity:
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Wired, lavaliere or clip-on Quantity:
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Wireless, handheld Quantity:
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Wireless, clip-on Quantity:
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| If you would like mic stands, please indicate how many of each kind you will need: |
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Table |
Quantity:
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Standing (straight) |
Quantity:
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Boom (podium use) |
Quantity:
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| Show a video |
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Video cassette (VHS) |
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DVD |
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Other
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| Record a lecture |
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Audio |
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Video |
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Both |
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| Show computer images or give a PowerPoint presentation |
| Do you have a computer to use? |
Yes
No |
| Is a screen needed for this room? |
Yes
No |
| Does your presentation have audio? |
Yes
No |
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Other (please describe and list any other accessories needed) :
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| DELIVERY, SETUP AND RETURN INFORMATION |
Due to the schedules of the IMC staff, it is unlikely that the equipment can be delivered to your classroom or be picked up when your class has ended. If possible we will lock it in a safe place at our convenience.
Please specify where the equipment can be safely locked:
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will pick up equipment
on
at
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Please deliver to
on
at
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Setup needed |
Describe setup:
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will return equipment
on
at
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Pick up equipment from
on
at
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| BORROWER'S SIGNATURE |
| *
I will see that all items check above will be returned to AC-234 before this date:
*
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| *
By checking this box, I understand that should I fail to return any of the items checked above or should they be returned with damages while on loan to me, my department will be billed for the amount of the repair or replacement cost. |
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| Please retype your name here:
*
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Verification Information
Type the characters you see in the image below. This ensures that a person, not an automated program, is submitting this form. You can refresh your screen to change the CAPTCHA images if you cannot read correctly. |
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75
College Avenue