Video Room and Phone Number:

IP# or Codec Assignment:

Your name:

Your email address:

Your phone number:

Choose the type of the event:
Credit Non Credit Seminar Meeting Faculty/Staff Training

If a credit course, select the number of credits earned for this course:
None 1 2 3 4 5 6 7 8 9 10

Event or Program name (if course, include Department and Course Number):

Name of the Instructor or Facilitator:

Date(s) of the event (if it is a recurring course, enter the start date and end date):

If your event occurs on a weekly basis, check the day(s) of the week on which it meets:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Starting time(s):

Ending time(s):

If a recurring event, enter any exception dates (holidays, etc.):

List any special arrangements or make any other comments:

Host Site:

Approved by:

Receive Site #1:

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