A. General Information

B. Scheduling Information

* 6. I will be using County Extension office sites:  yes  no If no, please skip to 7. (Please note: This does not guarantee the use of each site. This is a request, only. You must verify the availability of sites by contacting each one BEFORE the event.) Select the attendee sites you wish to use from the list below (select all that apply from the list below):

All County Sites Adams Alma Antigo Appleton Ashland Baldwin Balsam Lake Baraboo Barron Black River Falls Bristol Chilton Chippewa Falls Crandon Darlington Dodgeville Durand Eagle River Eau Claire Elkhorn Ellsworth Florence Fond du Lac Green Bay Green Lake Hayward Hurley Janesville Jefferson Juneau Keshena Kewaunee La Crosse Ladysmith Lancaster Manitowoc Marinette Marshfield Mauston Medford Menomonie UW-Stout, Menomonie Merrill Monroe Montello Neilsville Oconto Oshkosh Phillips Port Washington Portage Prairie du Chien Reedsburg Rhinelander Richland Center River Falls Shawano Sheboygan Falls Siren Sparta Spooner Stevens Point Sturgeon Bay Sturtevant Superior Viroqua Washburn Waukesha Waupaca Wausau Wautoma West Allis (Milwaukee) Whitehall Wisconsin Rapids

For statewide coverage (1 site in each county, select "ALL County Sites." DO NOT select individual sites for statewide programs. OR select individual sites from the list, as needed *To select multiple sites, use Ctrl + Click (PCs) or Shift + Click (Macs)

* 7. How many phone lines do you need? 

* 8. How many sessions will this program be? 

* What is the duration of EACH session - in minutes (e.g. 60, 75, 90, etc.)?  (15 minute minimum)

* 9. Will the conference have (check all that apply):

Incoming Calls (participants place calls in to WisLine bridge)

 800 number (long distance charged to dept.)
 608 number (participant pays long distance)

 Outgoing Calls (WisLine operators place calls to participants)

10. Moderator's Name (if different than coordinator):

Moderator's email address (e.g. username@servername.edu):

11. Participants' Names and Phone Numbers (for outgoing calls, only):

* 12. When would you like to hold your conference?

Please list all days, dates, and times you are requesting for your conference(e.g. Mon, 7/8/98, 8:30-10 am). Remember to avoid conflicts with State of Wisconsin holidays.
(You may enter each requested date as a separate line of text.)

13. Exceptions: List all days or periods of time during which your program should NOT be Scheduled:

C. Enhanced Services:

D. Program Category

* 15. What type of institution is sponsoring this program? (Check One)

Wisconsin State Government

Other Government

University of Wisconsin Institutions

Other/non-profit

E. Billing Information

Please enter billing information in the appropriate box. We must have billing information before we can schedule your conference. If you are a returning user with a current conference code listed above, and there are no changes in your billing account, you may skip this section.

* 16. Account Numbers:

Purchase Order Number or Blanket Account Number (Non-UW users)
Blanket Account Number (UW users)
Direct Charge: Fund/Acct/Unit/Div/Dept/Activity/Class Code (UW Users):
Credit Card: This is not a secure Web site. You will be contacted for credit card information by WisLine reservations following the receipt of this form.	Yes, I will charge this to a credit card. Please call me for credit card information.

17. Account Information(if different than coordinator)

Billing Name:
Billing Department:
Billing Street Address:
Billing City, State, Zip:

Remarks:

Request Submitted By: