*Please review the DWC Rules and Procedures for Requesting a Video/CD/DVD Loan website before completing the following form.

DWC RESOURCE CENTER AUDIOVISUAL LOAN REQUEST FORM

This form must be used to request audiovisual programs. One form must be filled out for each requested show date. Up to three videos are allowed per show date. All information must be complete for orders to be processed. Videos are for use in the state of TEXAS ONLY.

Please Print:

Account No. __________________________________ Fax No. ______________________

Company Name: ________________________________ Phone No. ____________________

Requestor's Name: ________________________________ Show Date:*___________________

Mailing Address or P. O. Box: _____________________________________________________

City: _________________________________ State: ___________ Zip: __________

Audiovisual Program Selection(s) No.: #1:_______________ #2: ________________ #3:_____________

Alternate Selection(s) No.: #1: _________________ #2: _____________ #3: _____________

Requestor has read and agrees to abide by the DWC Resource Center Audiovisual Loan Procedures. Requestor will return the audiovisual program to the DWC Resource Center on or before the Date Due ** shown on the Audiovisual Usage Form included with your audiovisual program. The Usage Form is to be completed and returned with your selection.

Requestor's Signature: _______________________________________ Date: _____________

Loan Procedures

¤ The DWC Resource Center includes a noncommercial audiovisual library to loan videos and slide programs for presentation in your safety training program. You may NOT request a video or slide program for public showing, loaning to others, or for any showing where a fee is charged. You are responsible for selecting appropriate media and for previewing prior to showing.

¤ Loans are made ONLY by written, signed requests made on the above form, and received in the Resource Center at least 21 days prior to your show date. Since titles are booked on a first come, first served basis, early requests will help ensure title availability. Requests may be mailed or faxed to the address below. Austin area patrons are requested to give up to 10 days notice. Three late returns will result in suspension of privileges.

¤ Up to three videos may be requested for one show date: *show date may be from one to seven days in duration.

¤ Please rewind videos and place in correct tape case, and/or place slides in correct sequence; and fill out Usage Form completely. Also, please be sure to note any damage/problems with the audiovisual materials on the Usage Form so they may be corrected. Willful failure to return borrowed media on request is viewed as theft of state property in violation of Section 31.03 Texas Penal Code. Such conviction could, depending on value, result in a fine not to exceed $500 (Class C Misdemeanor) or confinement of up to 10 years and a fine up to $10,000 (Third Degree Felony). Failure to fill out the usage forms may result in suspension of future service.

¤ **The Due Date shown on the Audiovisual Usage Form is the date the program is due back in Austin. Returns must be made by overnight or two-day courier service, e.g. UPS, Federal Express. Video tapes must be insured for $200.00 per tape. In the event of loss, the requestor agrees by signing the Audiovisual Loan Request form to replace the audiovisual program promptly. Failure to do so will result in collection efforts and/or referral to the Office of Attorney General as appropriate.

¤ Copyright regulations PROHIBIT any duplication or tampering of the videos. Anyone violating the regulations may face a misdemeanor charge. Your completed request form is your agreement not to copy or videotape the program. Violations of Federal Copyright laws will result in the immediate suspension of borrowing privileges and prosecution by the copyright owner can result in financial penalties and/or jail.