Media Services
Audio Visual Request Form

Extension: Department:
Today's Date:

Term Agreement (required)
I agree to hold myself financially responsible for any loss or damage which may occur to the equipment while it is in my care and agree to keep said property in good and proper repair as determined by the District. I agree that no person other than myself will be allowed to use the equipment and that I will return it to the District on the date stated below. (must be checked to be processed)

Name of Event/Class:
Weekday of Event /Class:
Starting Date of Event/Class:
Start Time of Event/Class: End Time of Event/Class: Recurrence/ Duration of Event/Class:

Select Campus: Coalinga NDC Lemoore District

Pickup or delivery date and time, if different from time of actual event:
Main Room or Area:
Please fill out requests for Breakout Rooms on separate pages if media requests differ by room!

Equipment Needed

Visual Equipment:
TV: | VCR: | DVD Player:
with CD drive: | with DVD drive:
Slide projector: Overhead projector:
Data Projector (with SVGA Cable): Video Camera:
Tripod: Easels: Number:
Other Visual equipment:

Audio Equipment

Portable Sound System:
(comes with 2 speakers, 2 mics, cd player and built-in mic stand)
Floor mic stand: CD Player:
Cassette Player: Tape Recorder:
Speaker for Laptop, VCR, or DVD:  
Conference Center Lemoore Audio:
Hand Held: |Head Set: |Laptop Set: | Internet Connection

Miscellaneous AV Equipment

AV Cart with AC:
Heavy-duty extension cord: Length:
Technical Assistance requested: Yes | No
set-up only: entire event: please describe dress code:

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