Videotape Request Form

First Name*:

Last Name*:

Phone*:

Email*:

Department*:

Course*:

Quarters for which you are a TA: Fall Winter Spring Summer

Appointment To Be Videotaped

First Choice

Date:

Day of the Week:

Time:

Building:

Room #:

Second Choice

No Second Choice

Date:

Day of the Week:

Time:

Building:

Room #:

Third Choice

No Third Choice

Date:

Day of the Week:

Time:

Building:

Room #:

Before submitting your request, please check to make sure you filled out all the required fields. Thank you!