Facilities Request Form

Please schedule equipment two weeks in advance of the date needed. The information you submit will be sent to the Media Specialist via email. You will be contacted within 48 hours (Monday-Friday) to confirm the scheduling of your request.
Do not assume that submission of the information via this form guarantees availability of the equipment.

Type of Request (check all that apply)
Room	Equipment	Media Request	Lab Supplies
Requestor Name
Telephone Contact Number:
Course Number::
Course Title:
Room and/or Equipment Request Information
Dates Requested
Begin Date	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December	Semester Request	Department
End Date	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December	---please select--- Fall Spring Summer	---please select--- Nursing HRP
Times Requested
Begin Time		Room Request (Kimball Tower)	Approx. Class Size
End Time		---please select--- none-equipment only Computer Lab, 113 KT Computer Lounge, 123 KT Video Conference, 710 KT Video Conference, 1110 KT 704 KT 720 KT 730 KT 825 KT 907 KT 1120 KT 1121 KT 1130KT 1140 KT
		Room Function Type	Building Request (if Other)
		---please select--- Class Time Presentation Lab Training Class
Equipment you would like us to provide (check all that apply):
	Laptop only
	Laptop with Projector
	Laptop / Projector / Internet Connection
	Overhead Projector
	Slide Projector
	Slide Projector with Cassette (sync attachment)
	TV / VCR
	Microphone
	Laser Pointer
Additional Requests:
Media Request Information
Media Title / Type (ADD dates if multiple titles)
Dates Requested
Begin Date	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December	Room Request (Kimball Tower)	Building Request (if Other)
End Date	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December	---please select--- none-equipment only Computer Lab, 104 KT Computer Lab, 113 KT Computer Lounge, 123 KT Video Conference, 710 KT 704 KT 720 KT 730 KT 825 KT 907 KT 1110 KT 1120 KT 1121 KT 1140 KT
Times Requested
Begin Time
End Time
Software Request Information
Software Title:
Quantity:
Description
Vendor
Item Number
Price
Bill To:
Special Instructions:
		Please press the submit button only once.
			University at Buffalo School of Nursing 1040 Kimball Tower 3435 Main Street Buffalo, NY 14214-3079 UB Privacy Statement Contact Webmaster  for comments / inquiry.