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California State University, Long Beach
Department of Nursing
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Learning Center Product Request Form
Faculty Only

The purpose of this form is to allow faculty members to submit requests for products they use with students in the Learning Center's simulation labs. In order to expedite your request in a timely manner, please complete as much information as possible about the products you are requesting. You can request up to three products using this form, submit additional forms for more than three products. When you have furnished all the required information click "Submit Your Product Request" button to send it to Maureen for processing. Thank you, Dr. Kumrow - Learning Center Director Direct any questions to me at: dkumrow@csulb.edu

* Indicates required information.

*Faculty Name:  

*Extension: *Email Address:

*Class Number:

*Undergraduate:   Graduate:

Number of Students:  

Will these products be used each semester?
If NO, please give us additional information on which semester and for how long.

Product #1 Name:
Type of Product:
Manufacturer:
Model:
Re-order Number:
Quantity Needed:
Additional Description of Product:

Product #2 Name:
Type of Product:
Manufacturer:
Model:
Re-order Number:
Quantity Needed:
Additional Description of Product:

Product #3 Name:
Type of Product:
Manufacturer:
Model:
Re-order Number:
Quantity Needed:
Additional Description of Product: