Diversity Video Loan Request Form

Your Name:

I am a current Evergreen:

Faculty      Academic Program:
Staff        Department:
Student    Student ID:


Campus Telephone:

Home Telephone:

Best Email:

Verify Email:

I would like to borrow the following video(s) (Enter complete title(s). If requesting more than one video, separate titles by semi-colons.)


I would like to pick up the video(s) on this date:

I will return the video(s) by this date (two week maximum loan time):