VIDEO NETWORK INFORMATION CENTER

Video Conferencing Request Form

Please fill out the request form for the video conference you have in mind. When the form is summitted, Larry Cannon will contact you for additional information and schedule the conference for you.

Items with an * indicate a required field.

CONFERENCE
Conference Name *
Conference Date *
Start Time *
End Time *
Duration
Events	Multiple Single
Additional Dates:
Number of students
Include students participating in all locations.

REQUESTOR
Please select one of the following if you are a Charter School:	Charter School PVX Charter School FX
Requestor Name *
BSU Department

Phone *
Mobile Phone #
E-mail address *
Budget Code *
Requested budget code is used for tracking purposes only.

FAR-SITE CONTACT PERSON
Please select one of the following if you are a Charter School:	Charter School PVX Charter School FX
Name *
Office Number *
Mobile Number
Email Address *

FAR-SITE TECHNICAL PERSON
Name *
Office Number *
Mobile Number
Email Address *
Additional Comments: