Requestor Information Form

Instructor:

Address Line 1:

Address Line 2:

Address Line 3:

Office Phone #: Home Phone #:

E-mail address:

Course # & Title:

Course Location/Center:

Course Starts: Course Ends:

Electronic Requests

Number of students: CRN/EPN:

After copyright permissions are obtained, your course pack will be scanned and placed in your Blackboard course shell for your students to access.

Other instruction:

If you would like a copy of this form, enter e-mail address: