Colorado Instructional Materials Center (CIMC) Professional Lending Library Request Form (CIMC phone number: 719.578.2195) Email this form to: cimcaphorders@csdb.org 1. Date: 2. Name of TVI or other professional requestions items: 3. Email: 4. Phone: 5. Administrative Unit (AU)/school district name: 6. Name of AU designated CIMC contact person: 7. Email: 8. hone: 9. Ship To: 10. Name: 11. Address line 1 (include school/building name, identify if this is a home address): 12. Address line 2: 13. City/State/Zip: 14. Only 1 item may be placed on each individual order form. Each item is individually barcoded which generates one “Materials Request ID” per item in the CIMC database. All professional materials are loaned for a period of 60 days and need to be returned to the CIMC. 15. Item name and/description: 16. ISBN 10: 17. ISBN 13: All information lines numbered 18 and higher will be filled out by the CIMC. 18. CIMC Barcode (CIMC will populate this line) 19. Date item checked out of inventory and shipped: 20. Please return item to the CIMC by this date: 21. Date item returned to CIMC inventory: 22. Materials Request ID number: 23. Catalog/KLAS ID: 24. Email AU order Received: 25. AU KLAS Patron ID: 26. Email AU Ship date: 27. Confirm AU Receipt: 28. Return reminder sent on: Revised.10.15.2020