Purchase Request for Audiovisual Materials

Please complete this form for any audiovisual materials faculty would like Audiovisual Services to purchase.
This form is designed to give AV sufficient information about usage to make best use of our budget.

Patron Information
*Name:
*10 digit Barcode# from ID:
*Department:
University Address:
*Home Phone:
*Office Phone:
*E-mail Address:

Audiovisual Materials Information
*Title:
Please Check:	Single Progam
	Series
Number of Programs in Series:
Materials Type:

Length of Program:

Year Produced:

*Date Needed(mm/dd/yyyy hh:mm):
Alternate Date(mm/dd/yyyy hh:mm):
Related materials requested:	Student Guide
	Instructor's Guide

Vendor Information
Vendor Name:
Address:

Course/Department Information
Name of primary course in which materials will be used:
Number of times the course is taught each year:
Estimated students enrolled in the course each year:
Names of other instructors teaching the course:
Other departments that you believe might use this materal:
Explain how this material will clarify the subject matter:

Preview Evaluation
Please complete this section if you have previewed the title. Thank you.

Reviewed by:

Please rate the following:
Accurancy and authenticity:

Relevancy to curriculum:

Technical Quality:

Aesthetic Quality:

Potential for stimulating inquiry:

Potential for stimulating creativity:

Overall Rating:

Scope:	Broad
	Narrow

Applicable subject areas:
I recommend this title for purchase:	Yes
	No

Purchase Request for Audiovisual Materials

Patron Information

Audiovisual Materials Information

Course/Department Information

Preview Evaluation