Central College Library
Audio-Visual Purchase Request Form

Name: _____________________________ Date: __________
Department: ____________________________________________

Title of Media: ____________________________________________
Format: __________________ ( i.e. video, film, CD, etc.)
Purchase Price: __________________

Supplier: __________________ Phone: __________________

_________________________ Address _________________________ City State Zip

Approximately how many times per year will this be used? _________
By how many students? _________
In which classes? _____________________________________________

_____________________________________________

Have you previewed this item? Yes _____ No ______

Please attach any pertinent information you may have i.e. brochure or catalog describing this title.

Department Chairperson Approval ________________ Date _______

RETURN THIS FORM TO RACHEL FLEMING, LIBRARY ACQUISITIONS Box 6500

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Date Request Received: ____________

Preview requested? Yes ______No _______
Date Preview Received: ___________ Date Preview Returned: _________

AV Budget Allocated: ______________
Spent to date: ______________

Purchase: approved ______ denied ________ hold ______
PO#:___________________________________________________
Date ordered: ___________ P.O. # _________ Date received: _____

REV. 11/8/06 RMF