Office of Medical Education

AV Service/MultiMedia Equipment Request Form

You MUST submit your request at least FIVE (5) working days in advance. Incomplete requests will not be honored.

Contact Information
Name:
Department:
Email Address:
Phone Number:
Status:	Medical Student Faculty/Staff Other (specify) Note: There may be charges assigned to you if this is a non-curricular event or if you are not associated with the School of Medicine.
AV Service Request
Event Name:
Event Date:
Start & End Time:	until
Event Location:
Event Description:	If you have an Agenda, please email the file to av@clc.umaryland.edu
Have you reserved the rooms for this event?	Yes No If you have NOT reserved your on-campus rooms, please do so immediately after filling out this form. Email rooms@clc.umaryland.edu.

Equipment Information
Equipment Request:
Special Request:
Rental Information
Pickup Date and Time:
Return Date and Time:
Date of Presentation:
Location of Presentation:
Have you used this equipment before?	Yes No
Will you need instructions for using this equipment?	Yes No

John Seebode
Khamraj Gransam
Ronnie Adams
av@clc.umaryland.edu
655 West Baltimore Street ~ BRB 1-012 ~ Baltimore MD 21201
Phone: (410) 706-3325 ~ Fax: (410) 706-0207

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Office of Medical Education

AV Service/MultiMedia Equipment Request Form

Contact Information

AV Service Request

Equipment Information

Rental Information