Saginaw Valley State University

It Services

Instructional Technology Center

Distance Education Form

* Denotes a required section. Please fill out all fields in these sections.

* Requestor\'s Information Requestor:

Department:

Email: (must be @svsu.edu)

Telephone:

Note: You will be contacted to confirm your request.

* About the Event Video Conference Event Name:

Estimated Audience Number at SVSU:

Choose One -

Location:

Choose One -

Requested Date:

1) (i.e. 05/08/2008)

Start Time:	Duration:

Additional Dates(s) Requested (if any)

Second Date:

Start Time:	Duration:

Third Date:

Start Time:	Duration:

* Participating Sites

First Site Location:	Audience number:

Contact Name:	Telephone:

E-mail:	Dial-up number:

For a point-to-point video conference, one site will initiate the call.
Which site will initiate? SVSU External Site

Additional Participating Site(s) (if any)

If you choose to connect with more than one site, a multi-point connection will need to be set up through the SVSU multi-point conference unit. (maximum 3 additional external sites)
Additional Site Location 1:	Audience number:

Contact Name:	Telephone:

E-mail:	Dial-up number:

Additional Site Location 2:	Audience number:

Contact Name:	Telephone:

E-mail:	Dial-up number:

Additional Site Location 3:	Audience number:

Contact Name:	Telephone:

E-mail:	Dial-up number:

* Requirements for the Video Conference Briefly Describe Your Needs:

All connecting sites must be confirmed by the Video Conference Administrator. Technical information and test calls may be necesary prior to the requested conference date.

Video conference rooms are reserved on a first-come, first-served basis. Education related video conferences are given first priority.

* Line charges may be incurred for video conferences. Charges will be billed to the requestor\'s department.

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