Mississippi History on Loan Reservation Form

Video Number: *
In the catalog, this is the combination of letters and numbers in brackets that immediately follows the title.
Title: *

Do you wish the Outreach Coordinator to substitute another title on the same subject if your choice is not available on the dates requested?

Substitute: Yes No

Scheduling periods are one to three days; request for "the week of" will allow greater flexibility in booking; a confirmation of show date will be mailed immediately after booking.

First Choice: *
Second Choice:
Name of Group:
Age Level:
Expected Number in Group:

Contact Information

First Name: *
Last Name: *
Institution/Organization:
Street Address: *
City: * State: *
Zip Code: *
Home Telephone Number: *
Work Telephone Number: *
Email Address: *

Reponsibilities of Borrower:

1. The borrower must return cassette or DVD by the date specified on the confirmation form.
2. The borrower is responsible for return shipping costs. Cassettes or DVDs must be returned by United Parcel Service or by First Class, U.S. Postal Service.
3. The borrower assumes financial responsibility for loss or damage to each cassette or DVD received and is expected to reimburse the Mississippi Department of Archives and History - Museum Division for loss of or damage to audiovisual material while it is in the possession of the borrower. The charge for a lost cassette or DVD is the current replacement price; the charge for out-of-print material is $300.00.
4. The borrower certifies eligibility as stated above.

I have read and accept the responsibilities of the borrower.