Instructor/Customer Name: (Required)

Instructor/Customer Email Address: (Required)

GroupWise User ID: (Required)

Instructor/Customer Telephone: (Required)

Instructor/Customer Department: (Required)

Instructor/Customer School: (Required) School of Dentistry School of Medicine School of Nursing School of Public Health Other (Not Listed)

Course Name/Number or Event Name: (Required)

Start Date & Time Needed: (Required) - 01 02 03 04 05 06 07 08 09 10 11 12/- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31/- 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018   : am pm

End Date & Time: (Required) - 01 02 03 04 05 06 07 08 09 10 11 12/- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31/- 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018   : am pm

Semester Order Days: Monday  Tuesday  Wednesday  Thursday  Friday  Saturday

Number of Students/Attendees: (Required)

Building: (Required) Abell Administrative Center Ambulatory Care Building-UofL Hospital Baxter Biomedical Research Building Carmichael Building Chestnut Street Parking Structure Instructional Building James Graham Brown Cancer Center K-Wing Keller Child Psychiatry Research Center Kentucky Lions Eye Research Institute Kidney Disease Program Kornhauser Library & Commons Building Medical-Dental Apartments Medical-Dental Research Building Myers Hall Research Resources Center School of Dentistry School of Medicine-Research Tower University of Louisville Hospital Other (Not Listed - Enter in room name below)

Room Number or Room Name: (Required)

Media Equipment Needed: (Required) Projectionist
Laptop Computer
i>clicker receiver (flash drive not provided)
Computer Data Projector
Overhead Transparency Projector
Slide Projector
Projection Screen
DVD Player
VHS Player (VCR)
Television (For use with VHS, DVD or Mobile Codec)
Video Projector (for use with VHS, DVD or Mobile Codec)
Mobile Codec (requires an ethernet connection & display)
Audience Response System (ARS)
Microphone & PA System
Camcorder & Tripod
Cassette Recorder/Player
Help Get Started (please detail below)

Other Needs/Instructions:

User Pickup:

SpeedType:

Authorized By: