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Request Form

Instructor/Requestor

Name:
Department:
Office Phone:		Cell Phone:
E-mail:

Distribution Requirements (check all that apply):

GavProVideo YouTube	iLearn
Public TV	Instructor Web site

Series Information:

If new series, series description:
Existing Series?	Yes No
Series Title:

Segment Information:

#	Segment Title	Description
1
2
3
4
5
6
7
8
9
10

Additional Comments:

If you have questions, please call Grant Richards at 408-848-4710,
or e-mail grichards@gavilan.edu.