Instruction Session Request Form

Faculty Name

Department

Telephone Number (Work)

Telephone Number (Home)

E-Mail Address

Preferred Contact Method
Please select an option. Work Telephone Home Telephone E-mail

Course Name/Number

Number of Students

Dates Preferred, In Priority Order
1.
2.
3.
4.

Hands-On Requested
Select One Yes No

Instruction Time Requested (please indicate a.m. or p.m.)
Start Time

End Time

Brief Description Of Instruction Requested

Database
Select One Yes No
If Yes, Please Specify

Web Sources
Select One Yes No

Reference Sources
Select One Yes No

Journals
Select One Yes No

Government Documents
Select One Yes No

Other (Please Specify)

Brief Description Of Assignment: