Video Conference Request Form - ND Dept of Health

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Video Conference Request Form

Fields marked with an * are required

*Event Name: Required

*Event Date: Required Must be a valid date

*Start Time: (Enter times as HH:MM AM/PM)Required Must be a valid time

*End Time: (Enter times as central time zone)Required Must be a valid time

*Submitter Name: Required

*Submitter Email: Required

*Submitter Phone: Required

*Will the video production studio be needed? (Seats 4) YesNo Required

*Will you be sharing a presentation via PC? YesNo Required

*Will a teleconferencing line need to be connected to the conference? YesNo Required

Teleconference Number:
Is this a MeetingOne number? YesNo

Remote Location #1

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #2

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #3

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #4

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #5

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #6

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #7

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #8

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #9

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

Remote Location #10

Remote site contact person's name:
Contact person's phone:
Remote site video calling name or internet address:

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600 East Boulevard Ave Bismarck, ND 58505-0200
Phone: 701-328-2372
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