IP Videoconferencing Request Form

How often do you expect to need the video conferencing facility? «

Once

Multiple times - series

List the date(s) with start and end times. «

Local Contact Name: «

(within at Johns Hopkins)

Local Contact Phone: «

Local Contact Email: «

Additional Local Contact Name (optional)

Additional Local Contact Phone (optional)

Additional Local Contact Email (optional)

How many participants will be at the local site?

Less then 15

More then 15

Remote Site Organization: «

Remote Site Contact Name: «

Technical person responsible for the videoconference from the other location

Remote Site Email: «

Remote Site Phone Number:

Remote Site videoconference IP address:

Emergency phone number or conference room phone number

Will there be slide presentations?

Yes, local	Yes, remote
No	Not sure

How many sites will participate in the videoconference?

Cost Center or Internal Order Number:

Fund Number:

Please use this space for additional information, remote sites, equipment test dates, firewall restrictions, or questions

Fields marked with "«" are required.