Distance Education Video Conference Reservation Form

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User Information Requestor: Email Address: Phone: Fax: Faculty/Staff: Email Address: Phone: Fax:   Event   $35.00 per hour IP Call/$50.00 per hour ISDN/$150.00 per hour ALL International calls Event/Course Title/No.: This is (a): [select type] New Change Cancellation Local Site: [select room] 45 Courtenay Drive Conference Room - Laptop Connection Available Basic Science 202 - Mac Only/Laptop Connection Available College of Nursing 220 - PC Only/Laptop Connection Available Other If OTHER Give Local Site(s): # of People Using Room Conference Type: [select type] IP - No Fee for Distant Education IP - Fee For Non-Educational Event ISDN - No Fee for Distant Education ISDN - Fee For Non-Educational Event Technician Needed: [select type] NO YES with No Fee for INITIAL SETUP ONLY YES with $30.00 per hour fee YES with $45.00 per hour fee/after hours   Billing Information   $35.00 per hour IP Call/$50.00 per hour ISDN/$150.00 per hour ALL International calls Company Name/ Department: Attention: Billing Address: Billing Address: City: State: Zip Code:   Remote Site Point of Contact 1 Site Name Site Phone Site Email ISDN #1: ISDN #2: IP Address: 2 Site Name Site Phone Site Email ISDN #1: ISDN #2: IP Address 3 Site Name Site Phone Site Email ISDN #1: ISDN #2: IP Address:   Days Of The Week   DE Rooms require 30 minute breaks between classes. Classes will not be booked back to back.   Date(s) Time(s)   From To From To Sunday Monday Tuesday Wednesday Thursday Friday Saturday   Equipment 35mm Slides DocCam DVD VCR Mac (BSB202) PC (CON220) Network Internet Excel PowerPoint Access Word Fax