Request a New Video for Use in a Course

(Librray will purchase electronic streaming format where available)

* Required fields cannot be left blank
* First Name:
* Last Name:
* E-mail:
* Department:
* Status:
* Course Number:

Title and Price
Title:
Catalog/Flyer Number:
Price:
(if known) 		$

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) 		Notify me when title is available
Replacement
Rush Order
Other

Video Topic
Select a topic area that best describes the DVD or videotape

Fund
For internal use only