Contact Information:

First Name *

Last Name *

Phone Number * () -

Email

Location of Presentation *

Building Room #

Date of Presentation * / /

mm dd yyyy

Time of Presentation *

Duration of Presentation (1 hour/1.5 hours)

Will you need assistance with using the equipment before the presentation?

Please enter any other information

	Projector		Projection Screen
	Laptop		Elmo (Document Camera)
	Overhead		Video Camera/Tripod
	Speakers		TV
	VCR Player		DVD Player
	Cassette Tape Recorder		Portable Podium
	Microphone/Microphone Stand		Other (specify below)