Western Illinois University-Quad Cities
Resource Center Technology Request Form
I wish to reserve the following equipment from ____/ ____/____ to ____/____/____.
Additional Class dates needed:
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Class Needed: ___________
Laptop Computers:
 Windows
WIU # ______________
Digital Camcorders/Cameras:
 Canon VIXIA HF R50 Camcorder
 Nikon Coolpix L830
Portable Digital Projectors:
 Epson Powerlite 1771
524522 524523 524524
 NEC NP40 505601
 NEC LT245 514590
 Mitsubishi 502910
 Mitsubishi 497579
Other Items:
 Sony Digital Recorder
 Karaoke Machine (dual cassette with
AM/FM radio; 2 microphones)
 Wireless Presenters
 Sony X Plod Boom Box
 IPads (write tag numbers below)
Portable Technology Carts:
 Archiving Cart (VHS to DVD conversion)
WIU # of other items to be checked out:
Accessories:
 Tripod
 Portable Projection Screen
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Faculty Name: ___________________________________ Signature: _______________________________________
(Please Print)
Checked out Date: ____________
Checked in by Tech: ___________________
Return Date:__________
Faculty and their department accept responsibility for the return of all equipment requested for usage to 3408.
All laptops should be returned to Technology after a week from the checkout date.
If you require it for a longer period of time please turn it in to Technology on a weekly basis and have them do any
needed maintenance on the machine and have them check it back out to you.
Student Reservation Information
Student Name: __________________________ Signature: ___________________________
(Please Print)
Student ID #: __________________________________________
Equipment is reserved in the order in which requests are received.
Please place completed form in Jon McKenna’s mailbox.
Date:_______________