NW Regional Equipment and Facilities Request Form
 

This is an internal form to be used by faculty and staff for reserving facilities and equipment in the region.  All requests will be directed to Judy Steinman at steinmanj@missouri.edu.  She will forward the requests to the appropriate individuals.  If you have any questions about completing this form, please contact Judy by e-mail or phone (660)726-5610.

Name of person making request

Beginning date of Event     

Event Begin Time AM PM    Event End Time AM PM

The facility will be available one hour before and one hour after the event unless other arrangements are made.

This event is reoccurring Monday Tuesday Wednesday Thursday Friday Saturday Sunday

End of date of Event    

Contact numbers in case the building needs to be closed.  (please include area code)

Home 

Office 

Cell    

e-mail

Program Name

Estimated Attendance
 

Location -mark those that apply

Hundley-Whaley     Regional Office   Buchanan County   No Location

Buchanan County comfortably seats 30 with tables

Regional office maximum capacity 20 people

Complete for Hundley Whaley Facility:

Kitchen needed   Auditorium (~200 seated with table) Southwest Room  (~12 seating with tables) Southeast Room(~20 seating with tables)

Equipment and Technology Usage

 I will be using the following

Centra  ITV ComputersProjectorSmartBoard Document Camera Microscope Mobile Resource Center  TV/VCR

NO EQUIPMENT NEEDED

Briefly describe the delivery of the program.

Computer Usage

Number of laptops requested  0 1 2 3 4 5 6     Will software need to be loaded?  NO YES

Person to pick up computers  Date for pick up

Person to return computers       Date of return 

Complete the following sections if you are responsible for scheduling ITV and Centra.  The information will be forwarded to Columbia on your behalf.  

ITV Usage

Originating Site

Other Sites and IP addresses 

Event needs:

PowerPoint  Marketing Assistance  NetMeeting  Handouts  Refreshments

MoCode and PS Account Number if billable event

Centra Request to be forwarded to Columbia.

Presenter and Presenter's e-mail

Co-presenter and e-mail

Participants and e-mail

Faculty are responsible for securing site facilitators, as well as set up and clean up of the facility.
Any technical assistance needs to be arranged prior to the event. 
Please use the text box below to add any addition comments, concerns or needs. 
 

A confirmation notice and other information for your event's success will be sent to you within 2 business days by the facility coordinator. 
A copy of your request appears after you click submit.  Print this screen for your records.

Form 040407