Equipment Request Form: Instructional Media Services: Indiana University South Bend

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Equipment Request Form

To request audio and video equipment, please complete the form below. We will contact you to confirm availability.

Check the equipment you are requesting. You may check more than one:

TV/VCR
Slide Projector
Cassette Tape Player
CD Disk Player
VHS Camcorder
Super VHS Camcorder
Tripod
Computer with Video Projector
RCPA
Wireless Microphone
Podium/Lecturn with Microphone
Phonograph/Record Player
Other
If other please explain:

Name:
E-mail
Phone:		Ext.
Dept:
Date(s):	/ / to / /
Days	Mon Tues Wed Thur Fri Sat Sun
Time(s) Begin & End:	to
Building:
Room(s):
Please note any special needs:

Kathleen J. Weidner
Coordinator/Webmaster
Instructional Media/Distance Technology
Indiana University South Bend
Voice: 574.237.4488
Fax: 574.237.6550
E-mail: kweidner@iusb.edu

1700 Mishawaka Ave. P.O. Box 7111
South Bend, IN 46634
Phone: (574) 520-IUSB

(574) 520-4872