This is a request for media ...

Using Media Advisory Committee funds

Using Media Advisory Committe funds WITH matching funds from program or department

Using department funds

*Name:

*Email:

*Position:

*Department:

*Phone:

Fax:

*Title of Media Requested:

English Translation of Title (if applicable):

Distributor:

*Format of Media:

Select Format DVD (preferred) Videotape 16mm film Other (If OTHER please specify:)

Price:

Is price estimated?

Yes

No

If using department funds, account number:

*If for Media Advisory Committee- Rationale for Acquisition (Please state why this purchase is needed and how it will be used. Teaching needs will be given priority.):

If you do not have distributor and/or pricing information please call or email Andrew Horbal at 412-648-5930 or arh6@pitt.edu. Additional funds can come from another program or department.

If you are submitting multiple requests, simply use your browser's BACK button to return to this form after clicking Submit. All of the data you entered will be retained, so it will not be necessary to re-key your personal information. You will need to retype the author, title and other information to submit a new request. After submitting your final request, please be sure to click the Clear the Form button to clear your personal information.