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Request a New Video for Use in a Course


* Required fields cannot be left blank


* First Name:

* Last Name:

* E-mail:

* Department:

* Status:

* Course Number:

Title and Price


Title:

Catalog/Flyer Number:

Price:
$

Producer


Producer's Name:

Address :

Phone :

Fax :

Web site:

E-mail :

Distributor


Distributor's Name:

Address :

Phone :

Fax :

Web site:

E-mail :

Rationale for Purchase


For example, is the item for classroom instruction
or for course reserves

Special Instructions


Will the item be placed on
course reserve or put into a
special location

 
Is this a
(select all that apply)
Replacement
Rush Order
Other

Video Topic


Select a topic area that best describes the DVD or videotape



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