SPECIAL EVENTS OFFICE (2011-13) Survey

This form is for SPECIAL EVENTS DEPARTMENT ONLY! Choose a different form if you do not work @ Special Events.

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1. Please select your name from the list:

Please select your name from the list:

2. Enter your extension or telephone number.

Enter your extension or telephone number.

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3. Enter the event name or meeting.

Enter the event name or meeting.

4. Enter the USI account# and fiscal agent's name.

Enter the USI account# and fiscal agent's name.

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5. Please enter room number(s) for delivery and separate if multiple rooms.

Please enter room number(s) for delivery and separate if multiple rooms.

6. Type event date with mm/dd/yyyy format & time needed. You may have a total of 5 dates on this form.

	MM		DD		YYYY	HH		MM	AM/PM
Date # 1	Type event date with mm/dd/yyyy format & time needed. You may have a total of 5 dates on this form. Date # 1 Month	/	Day	/	Year	Hour	:	Minute	AM or PM
Date # 2	Date # 2 Month	/	Day	/	Year	Hour	:	Minute	AM or PM
Date # 3	Date # 3 Month	/	Day	/	Year	Hour	:	Minute	AM or PM
Date # 4	Date # 4 Month	/	Day	/	Year	Hour	:	Minute	AM or PM
Date # 5	Date # 5 Month	/	Day	/	Year	Hour	:	Minute	AM or PM

7. Enter ENDING time for each of those events noted above when equipment may be picked up.

	HH		MM	AM/PM
Date # 1	Enter ENDING time for each of those events noted above when equipment may be picked up. Date # 1 Hour	:	Minute	AM or PM
Date # 2	Date # 2 Hour	:	Minute	AM or PM
Date # 3	Date # 3 Hour	:	Minute	AM or PM
Date # 4	Date # 4 Hour	:	Minute	AM or PM
Date # 5	Date # 5 Hour	:	Minute	AM or PM

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8. Select day(s) of the week when equipment is needed.

Select day(s) of the week when equipment is needed. Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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9. Select equipment from the list below. If you need more than one, please specify.

Select equipment from the list below. If you need more than one, please specify. Compact Music System (has CD and cassette tape player)

Digital Camera (sign/pick up from IT)

Digital video camcorder (sign/pick up from IT)

Easel/flip chart only (no paper)

Easel/flip chart w/ paper (put fiscal agent's name and account # on question #4)

Extension cord

Flip video camcorder (sign/pick up from IT)

LCD data projector

LCD data projector with VCR/DVD player

Microphone- Lavaliere

Microphone- Wireless

MP3 digital recorder

Overhead transparency projector

Overhead transparency projector with acetate roll

Podium - Stand-alone (built-in mic stand and mic) Note: not available in ED1101 & LA 0101

Podium to be placed next to desk in Kleymeyer

Portable Amplifier (includes lav and hand-held mic)

Pro sound/PA/music system for large audio events (Must request and pay for ITS Technical Support)

Projection screen

Slide projector

Slide projector with 80 slide tray

TV with DVD/VCR and scan converter

TV with DVD/VCR combination player

Need more than one or something not on list? Specify here.

10. Need equipment for Mitchell, Kleymeyer or Forums? Select options below. If not, skip to #11.

Need equipment for Mitchell, Kleymeyer or Forums? Select options below. If not, skip to #11.

11. Additional equipment needs? Please specify here.

Additional equipment needs? Please specify here.

12. Please indicate below if advance technical support is needed. Please include fiscal agent's name in OTHER.

Please indicate below if advance technical support is needed. Please include fiscal agent's name in OTHER. This event needs to be recorded.

I need technical support for this event.

Other (please specify)

PRINT A COPY OF THIS FORM and review before finalizing your order.