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University of Texas at Austin
ISDN and Video Conference Request Form (Request to be initiated and filled out by UT Austin Department) 

Please return the completed form to
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The following information is needed to setup, test and reserve your video conference request. One form is needed for each conference requested. Return to video-scheduling@ots.utexas.edu 


One form is needed for each conference requested. 

1. Date: Test --	___________ (mm/dd/1999) Conference -- ____________

2. Time: Test --	Start Time ________ Central 
	Time Stop Time ________ Central Time

Conference -- Start Time ___________ Central Time 
		Stop Time __________ Central Time


3. UT Component Site:
UT Institution and Campus ->
Austin Building ->RLM Room -> 

4. UT Component Site's technical contact name: 
	Name -> Don Patterson <d.patterson@mail.utexas.edu> 

5. UT Component Site's technical/trouble number during conference: 
	Don Patterson <d.patterson@mail.utexas.edu> Phone -> 232-4733 

6. Austin Control Room technical contact: Sandra Johnson/Bobby Wawak 

7. Austin Control Room technical/trouble number: 512/471-8530 

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8. Remote Conference Site:
Institution Name and Campus -> 
 		Room -> 

9. Remote Conference Site's technical contact name: 
	Name -> 
	Phone ->			
	E-mail -> 

10. Remote site's technical/trouble number during conference:
	 Phone -> 	

11. Remote site's video conferencing equipment type: 
	Equipment type -> 	

12. Remote site's equipment mode: -> 
	MUST be 'standards' STDS 

13. Rate of call (min=dual 56/64k, max=bonded 336/384k): 
	Rate -> 

14. Who will initiate the call? : 

IF UT AUSTIN IS INITIATOR OF CALL (dials out to remote site): 

a) Remote site's ISDN Telephone number: ->  

b) UT account number to bill (actual charges + $50 event fee) 
	Acct. Number ->  

c) Name of person with signature authority for this account: ->  


IF REMOTE SITE INITIATES CALL (dials in to UT Austin): 

d) UT's ISDN # will be forwarded to technical contact in item 9 above.


15. Short descriptive purpose of the request: ->
--> 
-->

16. Benefit to the University of Texas:
> 


Please be sure to forward the filled out form to: video-scheduling@ots.utexas.edu 

Rev. 2/16/1999