Videoconference Request Form - SIU School of Medicine (revised 9/19/08)

RED (required) - BLUE (provide details if applicable)
Meeting Name: (40 characters max)
Meeting Purpose:
Requested by:


The requester is responsible for notifying all meeting attendees. List alternate contact in NOTES section.

Requester Phone #: (ex.333-333-3333)
Requester Email: ONE email address only

Meeting Times - automatically connected sessions will connect and disconnect at these times. Plan accordingly.
Start Time:
End Time:

Videoconference reservations will be made no more than one year in advance. (date format mm/dd/yyyy)
Meeting Date 1:
Meeting Date 2:
Meeting Date 3:
Meeting Date 4:
Meeting Date 5:
Meeting Date 6:

Reserved Meeting Rooms: If "New Location" or "Other" is selected or if more than 6 locations are needed, put details in the NOTES section:
You MUST reserve your meeting rooms - Meeting Rooms (SIU-SM network access only)
Select at least TWO locations
Location 1:
Location 2:
Location 3:
Location 4:
Location 5:
Location 6:

Presenter Location (if known):
If you select a presenter location, you MUST ALSO select this location in one of the "Location" boxes above.
If the presenter(s) needs additional technology (laptop, projector, etc) you MUST list those details in the NOTES section below.

NOTES - Enter all information about location preferences, equipment needs, technical support requests, type of presentation, etc.
New Location? Please list - City, State, Name of Institution, Room Identification, Technical contact person (name, phone #, email), IP address or ISDN # of equipment.

Please double check your entries before submitting this form.