Name: _______________________________________________________________________

Address: _____________________________________________________________________

City: ____________________________ State: _____________ Zip: ____________________

Telephone: (____)___________________ Email: ____________________________________

_____Member of the general public; copy is for personal use only.

_____UWM Community Member: ___ Faculty/Staff ___ Student

Copy is for one-time, educational use only (please state use; include course number):

______________________________________________________________________

Material Requested:

Date of film: _________________________________________________________________

Specific description of film (attach sheet if necessary, and include specific seconds of film requested):

____________________________________________________________________________

Format Requested:

___VHS

___ DVCam

___DVD-R (please note: not all softwares and DVD players will play the DVD-R)

Delivery Requested:

___ Mail to the above address (shipping and handling fee will be applied)

___ Will pick up

___ FedEx – your number: _________________________________________