AudioVisual Request Form

If you need to schedule a room, please be sure to fill out the Room Request Form.
Please note that your AV order is not finalized until you receive written confirmation via email.

* Notes a Required Field

Step 1. Contact Info

* First Name: * Last Name:

* Phone: () -

* Email: Department: Mail Code:

* Index Number:

Step 2. Event Info

* Event Title:

* Location: Including facility (SOM Campus, Hillcrest, or La Jolla) and room number

* Start Date: (mm/dd/yyyy)

* End Date: (mm/dd/yyyy)

* Actual Start Time: : * End Time: :

Recurring Event? Yes No If Yes, please indicate the repeat pattern (i.e. 1st Tuesdays, every Monday and/or specific dates)

User's Name: (if different than contact name)

Step 3. AV Equipment & Services

* I need the following equipment/services for this event:

35mm Slide Projector	Audience Response in Liebow	Other AV equipment needs:
Computer - Mac	Computer - PC Laptop
Internet Connection	Laser Pointer
LCD (Data Video) Projector	Microphone - Wired
Microphone - Wireless	Overhead Projector
Speaker Phone	Television Monitor
VHS Player / Recorder

Step 4. Additional Information

Medical Education Directory

MedEd Administration:

MedEd Offices:

MedEd Services:

AudioVisual Request Form

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