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Videoconference Program Request Form

Use this form to request videoconference time for courses, programs and meetings. This is a request, only. You will be contacted to complete the scheduling of this program. You will receive a confirmation of your request after we confirm with each site you have requested. Please complete all information on this form.

A) General Information
B) Category:
    * 1. Type of Program and sponsoring institution:
      Internet2 Commons MCU Request (UW Madison departments only)
C) Scheduling Information

    * 3. Requested Day(s) of the Week:

      First Choice of Day(s):

      Second Choice of Day(s):

    * 4. Requested date(s) (please list all that apply to this program):

    * 5. Requested Times:

D) Videoconference Information
    * 1. How will we make the connections for this conference (check all that apply):

    * 2. Is this a (check one):

        If checked, list both requested locations:

        If checked, list all requested locations and approximate number of people per site. For a list of publicly-accessible sites in Wisconsin, please visit http://www.uwex.edu/ics/video/video_sites.cfm
        Site Name # of Attendees


    4. Equipment/technology needs for instructor or moderator (may not be available at all locations, extra charges may apply):

    5. Equipment/technology needs for participants (may not be available at all locations, extra charges may apply):

    * 6. Would you like this program recorded?

    * If you would like your program recorded, please choose from the following options:

E) Billing information
    * 1.) How do you want this program billed?
      (UW, only)

        (for Internet2, type "Commons" - UW Madison only)

      (This is not a secure Web site. You will be contacted for credit card information following the receipt of this form)

    2.) Account Information (if different from coordinator):

F) Misc:

    Are there any publication or other deadlines which we should be aware of for this event/program?

    Please tell us anything else you feel is essential to the scheduling of this program.

G) Request submitted by:

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