Revised September 2019
Phone (661) 722-6451 FAX (661) 722-6452
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Antelope
Valley
College
Attach information regarding requested media, such as order form, yer, copy of online
information, etc.
MEDIA PURCHASE REQUEST
Date Extension
Requested by Dept/Division
Print
For Ofce Use Only
Notations
Media Title
Suggested Vendor
Which format are you requesting?
❑ DVD ❑ Blu-Ray
Media must be 508 compliant. Identify which applies.
❑ Captioned ❑ Subtitled
Signature of Requestor
Vendor Used:
Accession Number Assigned:
Special Note