This form is used to request that a video be displayed on the Technology Plaza Screen Display

How to use this form:

1. Read the instructions before using this form.
   Failure to follow these guidelines will result in your video not being displayed.
2. Fill in the information in the text boxes below then click on the "Submit Request" button at the bottom. This will create the form with the required information. Print and send the completed form to Burdick Hall 116, BH 106 or fax it to 450-5365.
3. Incomplete forms will not be processed.

Note: Due to the complications of keeping staff on hand to operate non-automated equipment, we are unable to show programs in loop unless they are pre-recorded in a loop on the recording medium.

	Review the Technology Plaza Usage Guidelines
Requestor Name:
Department Name:
Address or Location
Telephone Number	- - (Area Code Not Required)
Affiliation with UCA	Staff or Faculty Student No Afiliation with University
Type of Media	DVD VHS Other
Desired Date For Showing:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031 , 201220132014
Desired Time For Showing:	: A.M. P.M.
Duration:	Hour(s) Minute(s)
Description of Video Content
Purpose of showing
Department Head or Faculty Advisor:
College Dean or Division Vice-President:

I have read and understand the Techology Plaza Usage Guidelines. Review the Technology Plaza Usage Guidelines