Video Request Form

Please fill out the form and fax it to Phillippa Ewing at 845-486-1981 or e-mail phillippa.ewing@nara.gov . For more information, or if you need assistance, please call 845-486-1977.

To e-mail the form, use the Adobe PDF or the Microsoft Word versions .

Today's Date:

Name:

School/Organization:

Address:

Phone:

E-mail:

Fax number:

Video Title:

Number of students expected to view video:

Grade level of students:

Dates requested:

Terms and Conditions for Use

• Video must be returned to the FDR Presidential Library no later than:
• Videos are to be used for educational purposes only.
• A fee cannot be charged to view a video.
• Cost of return postage will be paid by the person requesting the video.
• Replacement cost for videos that are lost, stolen, or damaged will be paid by the person to whom the video was checked out.

I agree to the above terms.

____________________________________ (Name) _______________ (Date)