Request New Video for use in a Course

(Library will purchase electronic streaming format where available)

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:

Website:

E-mail:

Distributor:

Address:

Phone:

Fax:

Website:

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:

Notify me when title is available

Replacement

Rush Order

Other

(select all that apply)

Video Topic:

Select a topic area that best describes the DVD or Videotape:

Fund:

For internal use only