<table border="0" width="100%"> <tr> <td> <h2>Media Order Form</h2> <br /> <table border="0" width="100%"> <tr> <td> <p align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:12pt; ">On-Campus Use Only<br /><br />Use this form when ordering media resources for delivery to your classroom.</span></strong></p> <p align="center"><span style="font-family:Arial, Helvetica, sans-serif; "><span style="font-size:10pt; ">Online requests require a minimum of 24 working hours to be processed, Monday thru Friday, excluding holidays and weekends.</span></span></p> </td> </tr> </table> <br /> <form name="mail" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post"> <input name="recipient" type="hidden" value="avsfilmlibrary@siue.edu,mdorris@siue.edu,jeprice@siue.edu,ftc_help@siue.edu" /><input name="required" type="hidden" value="email" /><input name="redirect" type="hidden" value="/lovejoylibrary/avs/thanks.shtml" /><input name="print_config" type="hidden" value="subject" /><input name="print_blank_fields" type="hidden" value="1" /> <table border="1" width="100%"> <tr> <td width="33%"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Name: <input name="a. Name" size="30" type="text" /></span></td> <td width="33%"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Dept: <input name="b. Department" size="30" type="text" /></span></td> <td width="34%"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Date: <input name="c1. Month" size="3" maxlength="2" type="text" /> / <input name="c2. Day" size="3" maxlength="2" type="text" /> / <input name="c3. Year" size="5" maxlength="4" type="text" /> <span style="font-size:8pt; ">(Please enter month/day/year, 01/01/2003 for example.)</span></span></td> </tr> <tr> <td height="29"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Phone: <input name="d. Phone" size="30" type="text" /></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Box #: <input name="e. Box No" size="30" type="text" /></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">E-mail: <input name="email" size="30" type="text" /></span></td> </tr> </table> <br /> <table border="1" width="100%"> <tr> <td width="10%"> <div align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Media #</span></strong></div> </td> <td width="36%"> <div align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Title</span></strong></div> </td> <td width="14%"> <div align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Date Needed</span></strong></div> </td> <td width="13%"> <div align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Delivery &amp;<br /> Pickup Time</span></strong></div> </td> <td width="14%"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Building &amp;<br /> Room Number</span></strong></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="g01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="g02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="g03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="g04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="g05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="g06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="g07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="g10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="g08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="g09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="g11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="h01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="h02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="h03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="h04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="h05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="h06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="h07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="h10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="h08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="h09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="h11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="i01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="i02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="i03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="i04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="i05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="i06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="i07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="i10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="i08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="i09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="i11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="j01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="j02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="j03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="j04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="j05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="j06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="j07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="j10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="j08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="j09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="j11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="k01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="k02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="k03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="k04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="k05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="k06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="k07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="k10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="k08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="k09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="k11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="l01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="l02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="l03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="l04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="l05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="l06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="l07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="l10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="l08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="l09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="l11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="m01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="m02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="m03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="m04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="m05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="m06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="m07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="m10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="m08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="m09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="m11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="n01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="n02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="n03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="n04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="n05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="n06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="n07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="n10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="n08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="n09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="n11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="o01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="o02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="o03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="o04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="o05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="o06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="o07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="o10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="o08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="o09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="o11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> <tr> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="p01. Media" size="12" maxlength="12" type="text" /></span></div> </td> <td rowspan="2"> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="p02. Title" size="45" maxlength="45" type="text" /></span></div> </td> <td rowspan="2"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="p03. Month Needed" size="3" maxlength="2" type="text" />/ <input name="p04. Day Needed" size="3" maxlength="2" type="text" /> / <input name="p05. Year Needed" size="5" maxlength="4" type="text" /></span></td> <td height="36"><input name="p06. Delivery" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="p07. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="p10. Building" size="1"><option selected="selected">Alumni</option> <option>Dunham</option> <option>Engineering</option> <option>Founders</option> <option>Peck</option> <option>Science</option> <option>Vadalabene</option> </select></span></td> </tr> <tr> <td><input name="p08. Pickup" size="5" maxlength="5" type="text" /><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><select name="p09. AM/PM" size="1"><option selected="selected">AM</option> <option>PM</option> </select></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Room: <input name="p11. Room" size="7" maxlength="7" type="text" /></span></td> </tr> </table> <br /> <table border="1" width="100%"> <tr> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><strong>Special Instructions:</strong></span> <br /> <textarea name="q. Special Instructions" rows="3" cols="75"></textarea></td> </tr> </table> <div align="center"><br /> <input type="submit" value="Submit" /></div> </form> </td> </tr> </table>