| Use this form when ordering media for pickup/checkout only. All requests require a minimum of 24 working hours to be processed, Monday through Friday, excluding holidays and weekends. |
| Name: | Address: | Date: / / (Please enter month/day/year, 01/01/2003 for example.) |
| Phone: | City, State: | E-mail: |
| Media # | Title | Pickup Date | Length of Checkout |
| | | / / | |
| | | / / |
| Special Instructions: |
