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This form must be completed and submitted.
Failure to do so will result in the request being declined.

Date of Video Conference:
Start Time:
End Time:
Name of Requestor:
Email Address:
Requestor Phone Number:
Department:
Contact Person:
Contact Person Phone Number:
Number of Participants:
Type of Conference :
		Call Originates From: Near End \| Far End

Far End Information:
List the Far End Site(s):
	First Time Connection with Far End Site?Yes \| No
Far End Contact:
Phone Number:
Equipment:
Video Phone #1:
Room Number:

	Equipment Needed at Near End: Document Camera? Yes \| No
Please Add Other Details as Needed:

Thank you for visiting UITS. This page can be found at:
http://uits.uark.edu/forms/videocon.htm