<h2>Media Pickup Request Form</h2>
<ul>
<li>This service is <strong>restricted to SIUE faculty</strong>.</li>
<li>This form is for <strong>DVD/VHS Media only</strong>.</li>
<li>Items in <em><strong>bold italics</strong></em> are required.</li>
<li>Up to five requests may be submitted per form. Please use as many forms as necessary.</li>
<li>After you send your request, an acknowledgment will appear on your Web browser screen.</li>
</ul>
<form name="mail" method="post" action="http://www.siue.edu/cgi-bin/FormMail.pl">
<input type="hidden" name="recipient" value="rkostec@siue.edu,kgallac@siue.edu" /><input type="hidden" name="redirect" value="http://www.siue.edu/lovejoylibrary/services/thank_you.shtml" />
<h3>Instructor</h3>
<table border="0">
<tbody>
<tr>
<th>Faculty Name:</th>
<td><input name="Name" size="30" /></td>
</tr>
<tr>
<th>Office Telephone:</th>
<td><input name="Sphone" maxlength="7" size="7" /></td>
</tr>
<tr>
<th>E-Mail Address:</th>
<td><input name="Email" /></td>
</tr>
</tbody>
</table>
<h3>Course</h3>
<table border="0">
<tbody>
<tr>
<th>Course Prefix:</th>
<td><select name="CoursePref" size="1"><option selected="selected">ACCT</option> <option>AD</option> <option>ADED</option> <option>ANTH</option> <option>ART</option> <option>AS</option> <option>BIOL</option> <option>BSED</option> <option>CE</option> <option>CHEM</option> <option>CHIN</option> <option>CI</option> <option>CIS</option> <option>CIV</option> <option>CJ</option> <option>CMIS</option> <option>CNST</option> <option>CS</option> <option>DANC</option> <option>DS</option> <option>ECE</option> <option>ECON</option> <option>EDAD</option> <option>EDFD</option> <option>EDUC</option> <option>EE</option> <option>ENG</option> <option>ENSC</option> <option>ENVS</option> <option>EPFR</option> <option>ESCI</option> <option>FAC</option> <option>FIN</option> <option>FL</option> <option>FR</option> <option>GBA</option> <option>GEOG</option> <option>GER</option> <option>GRK</option> <option>GRN</option> <option>HE</option> <option>HED</option> <option>HIST</option> <option>HS</option> <option>HUM</option> <option>IE</option> <option>IME</option> <option>IS</option> <option>IT</option> <option>ITAL</option> <option>KIN</option> <option>LAT</option> <option>LIBS</option> <option>MATH</option> <option>MBA</option> <option>MC</option> <option>ME</option> <option>MGMT</option> <option>MKTG</option> <option>MS</option> <option>MSC</option> <option>MUS</option> <option>NURS</option> <option>OR</option> <option>PAPA</option> <option>PE</option> <option>PHAS</option> <option>PHEP</option> <option>PHIL</option> <option>PHPR</option> <option>PHPS</option> <option>PHYS</option> <option>POLS</option> <option>PROD</option> <option>PSYC</option> <option>RUSS</option> <option>SAB</option> <option>SCI</option> <option>SOC</option> <option>SOCW</option> <option>SPAN</option> <option>SPC</option> <option>SPE</option> <option>SPPA</option> <option>STAT</option> <option>THEA</option> <option>UNIV</option> <option>WMST</option> </select></td>
</tr>
<tr>
<th>Course Number:</th>
<td><input name="CourseNo" maxlength="4" size="4" /></td>
</tr>
<tr>
<th>Section Number:</th>
<td><input name="SectionNo" maxlength="6" size="6" /></td>
</tr>
<tr>
<th>Academic Term:</th>
<td><select name="Term"><option>Spring 2011</option> <option>Summer 2011</option> <option>Fall 2011</option> <option>Spring 2012</option> </select></td>
</tr>
<tr>
<td><br /></td>
</tr>
</tbody>
</table>
<h3>DVD/VHS 1</h3>
<table border="0">
<tr valign="top">
<th>Material Format:</th>
<td><input name="Loan1" type="radio" checked="checked" value="2 hour" />DVD<br /><input name="Loan1" type="radio" value="3 hour" />VHS</td>
</tr>
<tbody>
<tr valign="top">
<th>Title:</th>
<td><input name="Author1" size="30" /></td>
</tr>
<tr valign="top">
<th>Call Number:</th>
<td><input name="Title1" size="30" /></td>
</tr>
<tr valign="top">
<th>Pickup Date:</th>
<td><input name="Publisher1" /></td>
</tr>
<tr valign="top">
<th>Pickup Time:</th>
<td><input name="PubYear1" /></td>
</tr>
</tbody>
</table>
<h3>DVD/VHS 2</h3>
<table border="0">
<tr valign="top">
<th>Material Format:</th>
<td><input name="Loan2" type="radio" checked="checked" value="2 hour" />DVD<br /><input name="Loan2" type="radio" value="3 hour" />VHS</td>
</tr>
<tbody>
<tr valign="top">
<th>Title:</th>
<td><input name="Author2" size="30" /></td>
</tr>
<tr valign="top">
<th>Call Number:</th>
<td><input name="Title2" size="30" /></td>
</tr>
<tr valign="top">
<th>Pickup Date:</th>
<td><input name="Publisher2" /></td>
</tr>
<tr valign="top">
<th>Pickup Time:</th>
<td><input name="PubYear2" /></td>
</tr>
</tbody>
</table>
<h3>DVD/VHS 3</h3>
<table border="0">
<tr valign="top">
<th>Material Format:</th>
<td><input name="Loan3" type="radio" checked="checked" value="2 hour" />DVD<br /><input name="Loan3" type="radio" value="3 hour" />VHS</td>
</tr>
<tbody>
<tr valign="top">
<th>Title:</th>
<td><input name="Author3" size="30" /></td>
</tr>
<tr valign="top">
<th>Call Number:</th>
<td><input name="Title3" size="30" /></td>
</tr>
<tr valign="top">
<th>Pickup Date:</th>
<td><input name="Publisher3" /></td>
</tr>
<tr valign="top">
<th>Pickup Time:</th>
<td><input name="PubYear3" /></td>
</tr>
</tbody>
</table>
<h3>DVD/VHS 4</h3>
<table border="0">
<tbody>
<tr valign="top">
<th>Material Format:</th>
<td><input name="Loan4" type="radio" checked="checked" value="2 hour" />DVD<br /><input name="Loan4" type="radio" value="3 hour" />VHS</td>
</tr>
<tr valign="top">
<th>Title:</th>
<td><input name="Author4" size="30" /></td>
</tr>
<tr valign="top">
<th>Call Number:</th>
<td><input name="Title4" size="30" /></td>
</tr>
<tr valign="top">
<th>Pickup Date:</th>
<td><input name="Publisher4" /></td>
</tr>
<tr valign="top">
<th>Pickup Time:</th>
<td><input name="PubYear4" /></td>
</tr>
</tbody>
</table>
<h3>DVD/VHS 5</h3>
<table border="0">
<tbody>
<tr valign="top">
<th>Material Format:</th>
<td><input name="Loan5" type="radio" checked="checked" value="2 hour" />DVD<br /><input name="Loan5" type="radio" value="3 hour" />VHS</td>
</tr>
<tr valign="top">
<th>Title:</th>
<td><input name="Author5" size="30" /></td>
</tr>
<tr valign="top">
<th>Call Number:</th>
<td><input name="Title5" size="30" /></td>
</tr>
<tr valign="top">
<th>Pickup Date:</th>
<td><input name="Publisher5" /></td>
</tr>
<tr valign="top">
<th>Pickup Time:</th>
<td><input name="PubYear5" /></td>
</tr>
</tbody>
</table>
<input type="submit" value="Send Request" /><input type="reset" value="Clear This Form and Start Over" /></form>