Reserve Request Form

Instructor and Course Information

Primary Instructor's Name: *

Additional Instructors' Names:

Department: *

Primary's Phone: *

Primary's Email: *

Course Number: *

Course Title: *

Loan Period

Please select a loan period: *

Hagerty - 2 hrs/standard

Hagerty - 4 hrs

Hagerty - overnight

Hagerty - 3 days

Hagerty - 7 days

Hahnemann - 3 hrs/no overnight

Hahnemann - 3 hrs/overnight after 4 p.m.

Activation Period

Quarter: *

Fall

Winter

Spring

Summer

Special Program/Rotation

Begin Date: *

End Date: *

Material Return Contact

Contact Name:

Phone:

Email:

Address:

City:

State:

Zip:

Citations

Reactivate my items already on reserve.:

Yes, please reactivate items I already have on reserve.

Citation:

Original Format:

Electronic

DVD/VHS

Other

If "Other":

Requested Reserve Format:

Same as Original Format

Electronic (up to 5 files may be uploaded at the bottom of the page)

Online DVD/VHS

Citation:

Original Format:

Electronic

DVD/VHS

Other

If "Other":

Requested Reserve Format:

Same as Original Format

Electronic (up to 5 files may be uploaded at the bottom of the page)

Online DVD/VHS

Citation:

Original Format:

Electronic

DVD/VHS

Other

If "Other":

Requested Reserve Format:

Same as Original Format

Electronic (up to 5 files may be uploaded at the bottom of the page)

Online DVD/VHS

Citation:

Original Format:

Electronic

DVD/VHS

Other

If "Other":

Requested Reserve Format:

Same as Original Format

Electronic (up to 5 files may be uploaded at the bottom of the page)

Online DVD/VHS

Citation:

Original Format:

Electronic

DVD/VHS

Other

If "Other":

Requested Reserve Format:

Same as Original Format

Electronic (up to 5 files may be uploaded at the bottom of the page)

Online DVD/VHS

Citation:

Original Format:

Electronic

DVD/VHS

Other

If "Other":

Requested Reserve Format:

Same as Original Format

Electronic (up to 5 files may be uploaded at the bottom of the page)

Online DVD/VHS

Citation:

Original Format:

Electronic

DVD/VHS

Other

If "Other":

Requested Reserve Format:

Same as Original Format

Electronic (up to 5 files may be uploaded at the bottom of the page)

Online DVD/VHS

Citation:

Original Format:

Electronic

DVD/VHS

Other

If "Other":

Requested Reserve Format:

Same as Original Format

Electronic (up to 5 files may be uploaded at the bottom of the page)

Online DVD/VHS

File 1:

File 2:

File 3:

File 4:

File 5:

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