Equipment Request Form
Full Name
*
First Name
Last Name
Campus
*
Campus Address
*
Campus
Campus address
City
State / Province
Postal / Zip Code
Phone Number (work or cell)
*
-
Area Code
Phone Number
Alternate Phone Number (different then above phone number)
*
-
Area Code
Phone Number
E-mail
*
Type of equipment requesting: i.e. Video camera, Chrome Book etc.
Equipment available for use
*
Please Select
Canon Camcorder(s) (Tripods Available)
Canon Powershot
Chrome Book(s) 25 available
Clickers
Drawing Tablet
Elmo Visual Presenter
iPad and Apple Pencil (2 Available)
Microphone
Panasonic Palmcorder
Portable Projector (Mini)
Portable Projector (Regular)
Olympus VR3 Recorder (4 Available)
Ziggi
Quantity
*
Date Equipment needed
*
-
Day
-
Month
Year
Date
Date Equipment to be picked up
*
-
Day
-
Month
Year
Date
Time equipment will be picked up between the hours of 8:00 a.m. - 5:00 p.m.
*
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Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date Equipment to be returned
*
-
Day
-
Month
Year
Date
Time equipment will be return to CTL between the hours of 8:00 a.m. - 5:00 p.m.
*
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Special Request (i.e. for additional time to borrow equipment) or comments
FOR OFFICE USE ONLY
Staff Initials
Date Equipment Returned
-
Month
-
Day
Year
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