Instructor Check Out Request
Return form to
James Wolfe
Roskens Hall room 405 (Ph. 554-3028, Fax 554-2879)
*Note: Instructor is responsible for pick up and return of equipment.
Check out dates: / / to / / (Availability limited to 5 days)
Pick Up Time: : am pm Return Time: : am pm
Instructor Name: Email:
Campus Address: Office Phone:
Location of Equipment:
Activity:
***Note- Please CHECKMARK next to items checked out.
Techpacks: Single Items:
Dell Laptop & Projector - Bag #____ Digital Still Camera & Bag #____
Digital Still Camera Document Camera
Macintosh Laptop & Bag #____
Windows Laptop & Bag #____
Digital Video Camera: Laptop Cart
Digital Video Camera - Bag #____ Portable Video Screen
Remote Microphone (2 pieces) Scanner #____
Boom Microphone Speakers
Tripod Video Projector
Other: __________ Other:___________
***Note: Disposable items such as Digital Video (DV) Tapes or DVD’s/CD’s will NOT be provided.
Special Directions:
________________________ ________________________
Instructor Signature Date
For Office Use Only
Date Request Received: ____/____/____ Initials: ____
Date Equipment Picked Up: ____/____/____ Initials: ____
Date Returned: ____/____/____ Initials: ____
Items missing/broken: