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*Required Fields
*Name:
*Email:
*Phone Number:
*Day of Class:
mm/dd/yy
*Pick Up Time:
*Return Time:
Equipment Needed:
Audio:
Tape Recorder
Select One
1
2
3
4
5
6
7
8
9
10
Dictaphone (micro cassette)
Select One
1
2
3
4
5
6
7
8
9
10
CD Recorder
Select One
1
2
3
4
5
6
7
8
9
10
Mini Disc Player
Select One
1
2
3
4
5
6
7
8
9
10
Camera:
Still, Digital
Select One
1
2
3
4
5
6
7
8
9
10
Video, Digital
Select One
1
2
3
4
5
6
7
8
9
10
Video, VHS
Select One
1
2
3
4
5
6
7
8
9
10
Projectors:
LCD/Data
Select One
1
2
3
4
5
6
7
8
9
10
Overhead
Select One
1
2
3
4
5
6
7
8
9
10
Slide
Select One
1
2
3
4
5
6
7
8
9
10
Video Playback:
DVD
Select One
1
2
3
4
5
6
7
8
9
10
VHS
Select One
1
2
3
4
5
6
7
8
9
10
Interactive
Remote Presenter
Select One
1
2
3
4
5
6
7
8
9
10
Special Instructions:
Office Use
ONLY
To be completed upon pick up of equipment:
MY SIGNATURE CONFIRMS THAT I HAVE RECEIVED THE ABOVE STATED EQUIPMENT AND THAT I ASSUME RESPONSIBILITY FOR IT, INCLUDING ALL DAMAGES AND/OR LOSS OTHER THAN WHAT MAY RESULT FROM NORMAL WEAR.
Signature:
PEID:
Description:
Media Services
Classroom Support Services
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