<table border="0" width="100%"> <tr> <td> <div align="center"> <h2><br />Student Media Order Form</h2> </div> <form name="mail" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post"><input name="recipient" type="hidden" value="avsfilmlibrary@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="env_report" type="hidden" value="REMOTE_HOST,HTTP_USER_AGENT" /><input name="print_config" type="hidden" value="subject" /><input name="print_blank_fields" type="hidden" value="1" /> <table border="0" width="100%"> <tr> <td> <p class="MsoNormal" align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:12pt; ">Use this form when ordering media for pickup/checkout only.</span></strong></p> <p align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">All requests require a minimum of 24 working hours to be processed, Monday through Friday, excluding holidays and weekends. </span></p> </td> </tr> </table><br /> <table border="1" width="100%"> <tr> <td width="33%"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Name: <input name="a. Name2" size="30" type="text" /></span></td> <td width="33%"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Address: <input name="b. Department2" size="30" type="text" /></span></td> <td width="34%"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Date: <input name="c1. Month2" size="3" maxlength="2" type="text" /> / <input name="c2. Day2" size="3" maxlength="2" type="text" /> / <input name="c3. Year2" 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. Phone2" size="30" type="text" /></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">City, State: <input name="e. Box No2" 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="15%"> <div align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Media #</span></strong></div> </td> <td width="46%"> <div align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Title</span></strong></div> </td> <td width="20%"> <div align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Pickup Date</span></strong></div> </td> <td width="19%"> <div align="center"><strong><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">Length of Checkout</span></strong></div> </td> </tr> <tr> <td> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="g1. Media #1" size="15" maxlength="15" type="text" /></span></div> </td> <td> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="g2. Title #1" size="55" maxlength="55" type="text" /></span></div> </td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="g3. Month #1" size="3" maxlength="2" type="text" />/ <input name="g4. Day #1" size="3" maxlength="2" type="text" /> / <input name="g5. Year #1" size="5" maxlength="4" type="text" /></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">&nbsp; <select name="g6. Length of Checkout #1" size="1"> <option selected="selected">7 DAYS</option> </select></span></td> </tr> <tr> <td> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="h1. Media #2" size="15" maxlength="15" type="text" /></span></div> </td> <td> <div align="center"><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="h2. Title #2" size="55" maxlength="55" type="text" /></span></div> </td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; "><input name="h3. Month #2" size="3" maxlength="2" type="text" />/ <input name="h4. Day #2" size="3" maxlength="2" type="text" /> / <input name="h5. Year #2" size="5" maxlength="4" type="text" /></span></td> <td><span style="font-family:Arial, Helvetica, sans-serif; font-size:10pt; ">&nbsp; <select name="h6. Length of Checkout #2" size="1"> <option selected="selected">7 DAYS</option> </select></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>