Instruction Request Form

Your Contact Information

* Full Name:

Department:

* Phone Number:

* E-mail Address:

Cornell Affiliation: (if applicable)

• Undergraduate Student
• Graduate Student
• Faculty
• Staff

Session Information

* What type of instruction would you like? (check all that apply)

• Class-related session
• Workshop
• Course web page
• Library assignment
• Special instruction session (for Cornell Cooperative Extension, emeriti, high school outreach, etc.)
• Tour and/or Orientation
• Consultation
• Other

Course Information: (if applicable: abbreviation, number, title, meeting times, etc)

Number of participants:

Unsure 1 - 25 25 - 50 50 - 75 75+

Explanation of instructional needs: (including assignment or topic information if known)

Preferred date of session:

mm/dd/yy

Second choice:

mm/dd/yy

Third choice:

mm/dd/yy

Comments: