* 1. Program Title:

* 2. Contact Name:

* Contact Email:

* Contact Phone (with area code):
Ext.

* Institution/Department:

* Street Address:

* City:
*State: *ZIP:

* 3. Presenter(s) Name(s):

In order to check availability and schedule your program we require the following information:

4. Meeting audio (choose one):

Regular phone audioconferencing
Internet (IP) audioconferencing
IP and phone audioconferencing

* 5. How many audio lines do you need? (if using phone audio):

* 6. Total number of computer connections needed (100, maximum):

* 7. Do you want participants to call in on audio using:

608 bridge number (participant pays long distance) 
800 toll-free bridge number (department pays long distance charges) 
Both

8. For returning customers, please give us your WisLine Web conference code:

* 9. All conferences are archived in LiveMeeting High Fidelity and are accessible on the web for 365 days at no charge. Would you like a copy of your conference?

 Yes, on CD ($15 charge)
 Yes, file download ($15 charge)
 No, thanks

* 10. What date(s) are you requesting?

Preferred starting date (MM/DD/YY):
Preferred ending date (MM/DD/YY):

* 11. At what time(s) will your session(s) be held?

Preferred starting time:

Preferred ending time:

* 12. List ALL dates, days, and times requested (Please list dates in MM/DD/YY format):
NOTE: We are closed on State of Wisconsin holidays (New Year's Day, Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Eve, Christmas, New Year's Eve)

13. Exceptions:
List all days or periods of time which your program should NOT be scheduled (i.e., Spring Break dates, exam days, etc.). If not applicable, enter N/A.

* 14. Will you use any UW System campus locations? Check all needed, or none if you will not use any UW sites:

UW-Eau Claire	UW-Green Bay	UW-La Crosse
UW-Milwaukee	UW-Oshkosh	UW-Parkside
UW-River Falls	UW-Stevens Point	UW-Stout
UW-Superior	UW-Whitewater	UW-Extension, The Pyle Center
UW-Baraboo/Sauk County	UW-Barron County	UW-Fond du Lac
UW-Fox Valley	UW-Manitowoc County	UW-Marathon County
UW-Marinette County	UW-Marshfield/Wood County	UW-Richland
UW-Rock County	UW-Sheboygan	UW-Washington County
UW-Waukesha County	UW Colleges Administrative Office	None
15. If you are using The Pyle Center, how many attendees do you anticipate?

16. Would you like to use the WisLine Web Online Registration System to register your participants?
For more information on the registration system, please visit http://www.uwex.edu/ics/wlweb/registration.htm.

 Yes, please set up my event in the registration system

Please enter your billing information in the appropriate box. We must have billing information before we can schedule your conference. We can accept the following types of payment (Note: This is NOT a secure site. Information you enter may be at risk.). Please check the appropriate type and enter the information requested.

Direct Invoice (State of Wisconsin Gov't, Non-profit, or Customers Outside Wisconsin, only).

Blanket Account (UW customers)

Account Number:

Direct Charge (UW customers)

Fund/Acct/Unit/Div/Dept/Act/Class Code:

Credit Card

We accept Visa, Master Card, and American Express. This is not a secure web site. You will be contacted for your credit card information following receipt of this form.

17. Bill To:
(returning customers may skip this section, unless there is a change in your billing information)

Name:
Institution/Department:
Street Address:
City, State, Zip:
Phone:	- - Ext:
Email:
Tax Exempt Number: (non-profits, only)

18. Are you delivering this course using any other distance technologies (i.e. videoconferencing, Internet, videotape, audio conference, etc.)? If so, please tell us what they are. If not, enter N/A.

19. Is there anything else we need to know about this conference/ program?

* Your name:

* Your email address:

* Confirm your email address:

* Your phone number: