Equipment Request Form


ITC Equipment Checkout Request Form EIU College of Education & Professional Studies Instructional Technology Center (Yellow Sheet)

* Last Name		* First Name
* Email Address		EIU Course Number
Department		Phone Number
Pickup Date		Pickup Time
Return Date		Return Time
Equipment Categories (Check all that apply)	PC Wireless Cart MAC Wireless Cart Digital Camera Digital Video Camera VHS Video Camera	Laptop Projector Computer on Wheels Video Conferencing Other	Turning Point Microphone Tripod
Request Description
Special Notes
EIU Tag Number(s)		Multiplier
* Indicates required field
Please do not assume that a request represents a reservation! Your request is not a reservation until you receive a confirmation number. You should receive a verbal or (preferably) e-mail confirmation number of you reservation within 48 hours of your request. If you do not receive a confirmatin number within 48 hours please contact the ITC at 581-3823. For a listing of available ITC Checkout Equipment and policies please visit: http://www.eiu.edu/~itc/ I certify that the property will be used exclusively for University-related business or activities, and agree to assume responsibility for the equipment during the time the property is checked-out. I understand that I am liable for any losses, damage or destruction, or impairment of function or useful life of the property that may result due to negligence or carelessness.



Recorded on:


The following fields are for ITC Staff Use Only (Do not complete)

Submit Date		Submit Time
Actual Return Date		Actual Return Time
Checkout Status	**	Customer ID
Request Taken By		Entered By
Checked In By
ITC Staff Notes

**Note: Checked out status O-Out, R- Reserved F-Finished.