Info Request for Audio,Video, Multimedia or Videoconferencing Services Contact Information Name Address Phone Email Billing Info Project Title/Objective Type of Service Choose One: School of Medicine Curriculum Non-Curriculum Other If Other, Please Specify: Date, Time, and Location Choose one: One Time Weekly Biweekly Monthly Location Start Date End Date Start Time End Time Alternative Date Selection Start Date End Date Start Time End Time For Videoconferences ONLY please fill out the following information in addition to the above information. A request for Digital Media only needs to fill out the above information. Remote Site Information First Remote Site: Contact Institution Phone Email Second Remote Site: Contact Institution Phone Email Third Remote Site: Contact Institution Phone Email Presentation/Media Requirements Choose: Laptop Document Camera Other If Other, Please Specify: Comments
