Instructor Information:

First Name   Last Name   PID

Department   Phone#   Email

Course (ie ENG 101)   Semester Fall 2012 Spring 2013 Other

Film Information:
Film Title   Call Number

Date Needed Jan Feb March April May June July Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2012 2013

Special Requests

Faculty Certification:

I certify that this film request is for preview for and/or use in a regularly scheduled class at the Chapel Hill campus of UNC (many titles are purchased with a binding contract for this campus only); as required by U.S. Copyright Law, the video title(s) requested will not be advertised for public exhibition; that all liabilities will be assumed by me for any litigation resulting from disregard to either contracts binding on the Media Resources Center or violations of the U.S. Copyright Law.

I further certify that my campus Department and I will assume responsibility for any damage or loss of materials while in my possession, as well as OVERDUE FINES for failure to return materials on time. It is MY RESPONSIBILITY to see that materials are returned by the correct due date.

All movies not on reserve for a class other than yours will have a pick up date the day before your showing and be due back to the MRC, by closing, the day after your showing.

Completion of this form does not imply the requested materials are available for use for your specified time and date. You will receive a confirmation email as soon as your request has been processed.

By hitting SUBMIT, you acknowledge that you have read the above information and agree to the terms of service.