Media Conversion Request Form

Please fill out the form for each item you wish to have converted.

* Indicates required field 

General Information

*Instructor Name:          

*Phone Number:           

*Email Address:            

School Affiliation:                                                               CLA HSE HSB LAW Other  

Media Information

Title:                                  

Artist/Author/Producer:   

*Is it Copyrighted?                                                        Yes No Not Sure  

*Has Copyright Permission Been Obtained?         Yes No Not Sure  

*Current Format:               

*Desired Format:              

*Convert Whole Media Item?                                                Yes No  

If you don't want the whole item converted, between which times do you want converted? *Note: If you are not able to determine exact start and stop times for editing, please make an appointment with us to help you identify these times.

Start Time:                          

Stop Time:                          

Completion

Requested File Title:        

Final File Location:            

Other Requests or Comments:

* Note: If file format is not indicated, CTL will automatically produce in .wmv format.