:: Videoconferencing - Proximity Videoconferencing

Thank you for scheduling with Proximity.

Please complete the following information to schedule a videoconference

Company Name:

WebReservation User Name:

Proximity Account Representative (if assigned):

Main Company Contact:

Address:

City:

State:
Zip:

Country:

Phone:
Fax:

Email:

Billing Contact:

Billing Address: (if different)

Billing City:

Billing State:

Billing Zip:

Billing Country:

Billing Phone:

Billing Fax:

Billing Email:

CONFERENCE DETAILS

Conference Date:
,

Transmission Speed:

Conference Time (New York Time):

From:	:
To:	:

# of sites in your conference:

Special Requirements

SITE #1

City/Location:

State:

Zip:

Country:

# of People:

This site will:	Place the call
	Receive the call

Who will Provide this Site?	Proximity to Provide
	Your Own Site

Lead Participant Name:

Lead Participant Email:

Phone:

Fax:

Room Coordinator Name:

Room Coordinator Email:

Phone:

Fax:

SITE #2

City/Location:

State:

Zip:

Country:

# of People:

This site will:	Place the call
	Receive the call

Who will Provide this Site?	Proximity to Provide
	Your Own Site

Lead Participant Name:

Lead Participant Email:

Phone:

Fax:

Room Coordinator Name:

Room Coordinator Email:

Phone:

Fax:

SITE #3

City/Location:

State:

Zip:

Country:

# of People:

This site will:	Place the call
	Receive the call

Who will Provide this Site?	Proximity to Provide
	Your Own Site

Lead Participant Name:

Lead Participant Email:

Phone:

Fax:

Room Coordinator Name:

Room Coordinator Email:

Phone:

Fax:

SITE #4

City/Location:

State:

Zip:

Country:

# of People:

This site will:	Place the call
	Receive the call

Who will Provide this Site?	Proximity to Provide
	Your Own Site

Lead Participant Name:

Lead Participant Email:

Phone:

Fax:

Room Coordinator Name:

Room Coordinator Email:

Phone:

Fax:

PAYMENT INFORMATION

Credit Card:

Card Number:

Expiration Date:

Name as it appears on card:

Type of Card:

Cardholder Verification Value (CVV2):
What is this?

CREDIT CARD MAILING ADDRESS (must be completed if paying with a credit card)

Billing Address:

Billing Zip:

PURCHASE ORDER INFORMATION

Purchase Order Number:

Purchase Order Reference Note:

CANCELLATION POLICY

Cancellation Policy:

1 business day or less:
Proximity Scheduling fee ($50 per site, per conference), plus 100% of room rental.
1-2 business days:
Proximity Scheduling fee ($50 per site, per conference), plus 50% of room rental.
More than 2 business days:
Proximity Scheduling fee only ($50 per site, per conference).

Yes, I accept Proximity's Cancellation Policy