Department:

Dept Billing Account #:

Contact Person:

Phone:

Fax:

E-mail:

Name of Conference:

Proposed Conference Date:

Conference Time: until (Pacific time zone):

Number of People @ SLO (approx):

Type of Connection: Select One ISDN IP Don't Know

Who will initiate the call:

Tech Contact for Testing:

Tech's Email:

Tech's Phone:

Equipment Type (Polycom, Tandberg, Kwangchung):

Type of Connection: Select One ISDN IP Don't Know

IP Address:

ISDN Number:

Internet2 GDS address, if known (Example: 001189 7561234):