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| 2 | <html> |
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| 3 | <head> |
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| 4 | <title>Equipment Request Form - The Classroom Support Pilot Project</title> |
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| 5 | <style type="text/css"> |
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| 6 | #author, #footer { font-style: italic; } |
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| 7 | th { font-weight: normal; text-align: right; vertical-align: top; } |
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| 8 | </style> |
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| 9 | </head> |
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| 10 | <body> |
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| 11 | |
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| 12 | <h1>Equipment Request Form</h1> |
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| 13 | <p id="author">Created by the Classroom Support Pilot Project</p> |
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| 14 | <p id="instructions">(Required fields are marked in <strong>bold</strong>.)</p> |
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| 15 | |
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| 16 | <!-- Generated by CGI::FormBuilder v2.12 available from www.formbuilder.org --> |
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| 17 | <form action="form.html" method="GET"><input name="_submitted" type="hidden" value="1" /><input name="_sessionid" type="hidden" value="" /> |
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| 18 | <table> |
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| 19 | <tr><th><strong class="required">Name:</strong></th><td><input name="name" size="40" type="text" /> </td></tr> |
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| 20 | <tr><th><strong class="required">Course Number:</strong></th><td><input name="course_number" size="20" type="text" /> </td></tr> |
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| 21 | <tr><th><strong class="required">Extension:</strong></th><td><input name="extension" size="20" type="text" /> e.g. x51234</td></tr> |
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| 22 | <tr><th><strong class="required">Email address:</strong></th><td><input name="email" size="40" type="text" /> e.g. name@host.domain</td></tr> |
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| 23 | <tr><th><strong class="required">Building:</strong></th><td><select name="building" type="select"><option value="">-select-</option><option value="JMZ">Jimenez</option><option value="KEY">Francis Scott Key</option><option value="LEF">LeFrak Building</option><option value="MMH">Marie Mount Hall</option><option selected="selected" value="SKN">Skinner</option><option value="TLF">Taliafero</option><option value="TWS">Tawes</option><option value="WDS">Woods Hall</option></select> </td></tr> |
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| 24 | <tr><th><strong class="required">Room Number:</strong></th><td><input name="room_number" size="20" type="text" /> </td></tr> |
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| 25 | <tr><th>Department:</th><td><select name="dept" type="select"><option value="">-select-</option><option value="AMST">American Studies</option><option value="LING">Linguistics</option><option selected="selected" value="PHIL">Philosophy</option><option value="none">none</option></select> </td></tr> |
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| 26 | <tr><th>I need a:</th><td><input id="equip_computer" name="equip" type="checkbox" value="computer" /> <label for="equip_computer">Computer</label> <input id="equip_vcr" name="equip" type="checkbox" value="vcr" /> <label for="equip_vcr">VCR</label> <input id="equip_dvd" name="equip" type="checkbox" value="dvd" /> <label for="equip_dvd">DVD Player</label> <input id="equip_projector" name="equip" type="checkbox" value="projector" /> <label for="equip_projector">LCD Projector</label> </td></tr> |
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| 27 | <tr><th>Preferred computer type:</th><td><input id="computer_type_pc" name="computer_type" type="radio" value="pc" /> <label for="computer_type_pc">Windows</label> <input id="computer_type_mac" name="computer_type" type="radio" value="mac" /> <label for="computer_type_mac">Mac</label> </td></tr> |
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| 28 | <tr><th>I would also like:</th><td><input id="extra_equip_internet" name="extra_equip" type="checkbox" value="internet" /> <label for="extra_equip_internet">Internet</label> <input id="extra_equip_zip_drive" name="extra_equip" type="checkbox" value="zip_drive" /> <label for="extra_equip_zip_drive">ZIP Drive</label> <input id="extra_equip_floppy_disk" name="extra_equip" type="checkbox" value="floppy_disk" /> <label for="extra_equip_floppy_disk">Floppy</label> </td></tr> |
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| 29 | <tr><th>This equipment will be used for :</th><td><input id="purpose_lecture" name="purpose" type="radio" value="lecture" /> <label for="purpose_lecture">A lecture</label> <input id="purpose_students" name="purpose" type="radio" value="students" /> <label for="purpose_students">Student presentations</label> <input id="purpose_guest" name="purpose" type="radio" value="guest" /> <label for="purpose_guest">A guest speaker</label> </td></tr> |
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| 30 | <tr><th>Additional requests or instructions:</th><td><textarea cols="60" name="special_needs" rows="8" type="textarea"></textarea> </td></tr> |
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| 31 | <tr><th>I recieved my equipment promptly:</th><td><input id="on_time_yes" name="on_time" type="radio" value="yes" /> <label for="on_time_yes">I agree</label> <input id="on_time_no" name="on_time" type="radio" value="no" /> <label for="on_time_no">I disagree</label> <input checked="checked" id="on_time_maybe" name="on_time" type="radio" value="maybe" /> <label for="on_time_maybe">I am undecided</label> </td></tr> |
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| 32 | <tr><th>I would recommend this service to others:</th><td><input id="recommend_yes" name="recommend" type="radio" value="yes" /> <label for="recommend_yes">I agree</label> <input id="recommend_no" name="recommend" type="radio" value="no" /> <label for="recommend_no">I disagree</label> <input checked="checked" id="recommend_maybe" name="recommend" type="radio" value="maybe" /> <label for="recommend_maybe">I am undecided</label> </td></tr> |
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| 33 | |
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| 34 | <tr><th></th><td style="padding-top: 1em;"><input name="_submit" type="submit" value="Submit" /></td></tr> |
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| 35 | </table> |
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| 36 | </form> |
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| 37 | <hr /> |
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| 38 | <div id="footer"> |
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| 39 | <p id="creator">Made with <a href="http://formbuilder.org/">CGI::FormBuilder</a> version 2.12.</p> |
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| 40 | </div> |
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| 41 | </body> |
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| 42 | </html> |
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