Rolling Prairie Library System

Distance Learning Equipment Use Application/Agreement

Phone: (217) 429-2586

 

 

Organization Name:  __________________________________________________________

 

Contact Name:  __________________________________      Phone:____________  ext. ______

 

Fax:  _______________________                    E-mail address:  ____________________________

 

Requested Date/Time for Conference/Meeting:

 

1ST Choice Date(s): _______________      Beginning time:  ______________     Ending time  _________

 

2nd Choice Date(s): ________________      Beginning time:  ______________     Ending time  _________

 

Meeting requirements (please check all that apply):

 

_____ Connection being made on the CMS/Illinois Video Network Telephone/Port number

 

_____ Connection being made Off NET (outside of the CMS/Illinois Video Network):

           (please check all that apply)

Local initiated call ________or Remote initiated call ________

Video System: Vtel  _______   PictureTel  _______  Other  ________

Phone Number:  _____________________

 

Line Speed (Off NET calls, please check one):

 

_____ 336         _____ 384         _____ 2x64(128)         _____   Not sure

 

Room Requested for V-tel:

_____ Distance Learning Room (16)

 

Room Requested for Satellite Downlink:

_____ Distance Learning Room (16)     _____ Large Meeting Room (25)

 

_____ Assistance with locating video rooms at remote locations

_____ Document Camera

_____ Video White Board

_____ Videotape the conference/meeting (tape to be provided by applicant)

_____ Special Needs (Please give detailed description):

 

Authorized Applicant Signature__________________________________    Date:    _________________

Rolling Prairie Library System Signature:  ___________________________  Date:     _________________

Web Page last updated: 05/22/2002