Teacher Video Request Form

Please fill out and submit the following form to request a Biotechnology Video. You should check our list of videos and know which one(s) you would like before continuing.

Browse the list online.

The video loan program is for North Carolina teachers only. You may request up to two videos at a time.

Videos are due two weeks after checkout. Teachers are liable for unreturned, lost or damaged videos.

Our video collection contains both VHS and DVD format. If both formats are available for a title, we will ship the DVD version unless the "VHS format" box is checked.
Please send VHS format if there is a choice.

Video title one:

Video title two (optional):

Date Needed (mm/dd/yyyy): / /

Don't Send After (mm/dd/yyyy): / /

First Name:

Last Name:

Email:
Occasionally, the Biotechnology Center may share your e-mail address with relevant non-profit educational organizations. If you do not wish us to share your e-mail address, please check this box.

School Name:
My school is in County.

Shipping Address: (no Post Office Boxes)
Home Address | School Address
Line 1
Line 2
City, ST, ZIP

Daytime Phone:

By clicking the Request Video button, I accept financial responsibility for this video/these videos.