Video Conference Request Form
Fields marked with an * are required

*Event name:
*Event date:  
*Start time: (Enter times as HH:MM AM/PM or use military time)
*End time:  (Enter times as central time zone)
*Name of person submitting the request:
*Phone number of person submitting the request:

*Will Gold Seal Center facilities be used?
Yes, lower level conference room
Yes, video production studio
No, this is a remote conference only
     Number of people participating at Gold Seal Center Video Conference/Studio:

*Will Radvision Click to Meet desktop video be used?  Yes  No
      Radvision Meeting Room Name or Meeting ID#

Check the box(es) if you will be using any of  the following audio/visual aids during your presentation:
PowerPoint slides
Videotape recordings
DVD video disk

*Will a telephone connection need to be made to the video conference? Yes  No
       If yes, please indicate the approximate number of telephone connections:

Remote Location #1
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #2
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #3
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #4
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #5
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #6
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #7
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #8
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #9
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address

Remote Location #10
     Remote site contact person's name:
     Contact person's phone number:
     Type of connection
         ND State System - Video Calling Name
         Internet  -  Internet IP Address
         ISDN  -  ISDN Address
 

           

 

 

 

Health Department Logo