:: Student Equipment Use Authorization ::
Media Distribution Services
756-7198 | mds.calpoly.edu
This equipment request is for the following specific course or project:

Authorization is for the following dates: ______________________________________________________


The following student(s) are authorized to check out equipment:
Name
1
2

Check the equipment needed:
Television/VCR CD Player/Audio Cassette Player
Slide Projector Handheld Audio Cassette Recorder
Public Address System DVD/VHS Player
Portable Screen Digital Audio Recorder
VHS Camcorder Power Presenter (Powerpoint Remote)
Tripod Other ____________________
IMPORTANT - PLEASE READ CAREFULLY
The following equipment requires verbal authorization from faculty as well as a signature. To help us efficiently complete your order please ask the authorizing faculty to call the MDS location where you will be reserving your equipment (Building 2 or 10) to authorize your order immediately after signing this form.

Picking up in Building 2 (Cotchett Education) - please call: 756-7198
Picking up in Building 10 (Erhart Agriculture) - please call: 756-6765

Laptop Computer PC/MAC Digital Still Camera
Data/Video Projector* Digital Video Camcorder
*Available Monday through Friday only
Media Distribution Services' equipment may be borrowed for course related/instructional use only. All equipment used for personal or ASI club use is subject to rental rates.

FACULTY AUTHORIZATION RESPONSIBILITY: The faculty's signature authorizes a student to use the equipment for specific course related work only.
Faculty Signature: Phone #:
Faculty Name (please print):
Verification (office use only) date called _________ date verified _________ employee initials _________