LOUIS STOKES HEALTH SCIENCES LIBRARY AND LEARNING RESOURCE CENTER

Facility Use Reservation Form

Dept/School/Organization______________________________________________________________

Contact Person ____________________________________ Phone ______________________________

Fax Number ______________________________________ E-Mail ______________________________

Date of Event_____________________ Time: Start __________________ End____________________

(Please allow for time needed to setup, breakdown, and clean designated area requested0 Title and Type of Event

(i.e., seminar, meeting, luncheon, reception etc.) _________________________________________

____________________________________________ _________________________________

Source of Funding (grant, project, external sponsorship) ____________________________________

Number of Attendees______________________Room(s)Requested__________________________

Equipment Needs (i.e., tele/med distance learning, audio/visual, tele/data, podium, etc.) _________________________________________________________________________________

_________________________________________________________________________________

Detailed Description of Requirements: (Production Schedule required for major special events)

SUBMIT THIS FORM TO:

Dr. Ellis Beteck

FAX: 202-884-1733

Approved________ Disapproved________