Revised September 2019
Item(s) will be returned on
Signature of Requester
REQUEST TO EXTEND USE OF EQUIPMENT/MEDIA
For Ofce Use Only
Approved
Authorized IMC Staff: Date
Alex Parisky, Shirlene Thatch, Cheryl Burleson, Kim Whitaker.
Date Time
Item(s) returned
Initials
Date of Request Extension/Phone Number
Requested by Dept/Division
I acknowledge receipt of the following listed IMC items to be used in connection with the instructional program of
Antelope Valley College or for professional development. It is understood that if the item(s) is needed by the IMC during
the extended loan period, it will immediately be returned upon receiving a request from the IMC staff.
Room number where item(s) will be kept
All off campus use requests require an Off Campus Request form approved in advance by the Manager, Instructional
Resources & Design
Print
Date Time
661.722.6451 Fax 661.722.6452
❑ Dry Erase Easel
❑ Small
❑ Large
❑ Document Camera
❑ Portable LCD
❑ Portable Screen
❑ Overhead Projector
❑ Other
Equipment
AVC Number
❑ Smart Cart (PC)
❑ Smart Cart (Mac)
❑ PC Laptop (available soon)
❑ Mac Laptop (available soon)
❑ VCR
❑ Television
❑ Display Easel
❑ How many?
Equipment
AVC Number
Media Title Accession Number
