SUBMIT A SEPARATE EQUIPMENT REQUEST FORM FOR EACH DATE AND LOCATION NEEDED. FORMS MUST BE
RECEIVED IN THE MEDIA SERVICES OFFICE, T-124, AT LEAST 2 WORKING DAYS IN ADVANCE OF DATE DESIRED.
MEDIA SERVICES
EQUIPMENT REQUEST FORM
 PLEASE FILL OUT COMPLETELY
AND
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Please confirm, at your earliest convenience, receipt of this form via my email address - ____________________
Contact Person: ___________________________ Org./Affiliation: _________________ Phone _______
Email: _______________________ Name of Event: _________________________________________
Day Desired: _________________ Date Desired: ___________________ Today’s Date:
_________________
Room: __________________ Actual Starting Time: ________ Completion Time: ________
DVD/VHS VCR/TV Playback
Data Projector (*for laptop/PowerPoint)
No audio required for presentation
Presentation WITH AUDIO
*NOTE:
users must provide their own laptop
Lectern Light
Overhead Projector (for transparencies)
Cassette Player/Recorder
CD Player (boom-box)
72” x 72” Tripod Projection Screen
Electrical Extension Cord
_______ft. required
Operator
Time: From: ____________ AM/PM
Until: ____________ AM/PM
House Sound – UTLC Gallery
House Sound –M218, M336
House Sound – Fieldhouse
Lear Auditorium – T429
*Laptop Presentation, without audio
*Laptop Presentation, with audio
Single Slide Projector Presentation
Dual Slide Projector Presentation
VHS Videotape Playback
CD/DVD Playback (stand alone unit on cart)
*CD/DVD Playback (via user’s own laptop)
Microphone on floor stand at Lectern
*NOTE:
user must provide their own laptop
Microphones
On Floor Stand @ Lectern
Table Mic
Lavalier
NOTE: A-200 arrangements should be made with
College of Architecture
Other:
I ______________________ will take responsibility for damage(s) to audio/video equipment requested for use at
this event. If equipment is found damaged/lost/stolen following event due to improper use, I understand a fee of
up to $1000 toward the cost of repair or replacement will be applied to my Banner Account.
FOR OFFICE USE ONLY - DO NOT WRITE IN THIS BOX – rev 7EM. 11-27-13
Date Rec’d:_______________________ Comments: _______________________________________________
Time: ___________________ AM / PM _________________________________________________________
Set-Up: _________ Return _________
OUTSIDE RENTAL CHARGE ______________________
Mail
Office
Fax
_______
Additional copies of this form can be found @ http://www.ltu.edu/studentactivities/importantforms.asp
Sunday
AM
AM
AM
Banner ID:
Signature:
___________________________________ __________________________
AM
For Student USE ONLY
click to sign
signature
click to edit
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