:: Videoconferencing - Proximity Videoconferencing

PROXIMITY Videoconferencing Room Information

Thank you for filling out our room information form to become a PROXIMITY affiliate! Please complete as thoroughly as possible. We will review your information and get in touch with you shortly.

Room Physical Address:

Company:

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

Country:

Phone:

Fax:

Mailing Address:
(If different from Physical Address)

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

Country:

Phone:

Fax:

Website :

E-Mail Address:

Reservation Contact:

Phone:

Fax:

Email:

Room Coordinator:

Phone:

Fax:

Email:

Please supply us with directions to your location.
Feel free to send a map as well for attendees use.

Rate Information:

Retail cost per hour:

Standard cost per hour:
(charge to PROXIMITY)

Regular Business hours when standard cost applies:

Is your room available
outside business hours?

Yes
No

Please indicate days when
your room is NOT available:

M	T	W	Th	F
Sa	Su

After hours availability:

From:
To:

After hours retail cost per hour:

After hours cost per hour:
(charge to PROXIMITY)

Taxes (percent)

Pricing and other comments:

Technical Information:

Telephone # in Videoconference Room:

Fax # in Videoconference Room:

System
Manufacturer
and Model:

Software Version:

Speeds (check all that apply):

112 224 336
128 256 384
512 768

H. 320 (ISDN,T1) H.323 (IP)

Technical Comments:

Network Protocol:

ISDN
Switched 56
IP (Internet Protocol)

Long Distance Carrier:

Does your system have an IMUX?

Yes
No

Make/Model:

Video Dial up Numbers:

Primary ISDN # :

Secondary ISDN # :

IP Address:

Video dial-up number comments:

Equipment:
(check all those that you have available,
include pricing if available):

	Document Camera	Cost:
	Auxiliary Camera	Cost:
	Electronic Whiteboard	Cost:
	VCR	Cost:
	Scan Converter	Cost:
	Large Display (>30")
	Dual Monitors
	Video Slide Projector	Cost:
	Audio only Interface	Cost:
	Capacity (number of people):
	Equipment and Room Capacity Comments:

Bridge Information:
(please indicate those that you are registered with):

AT&T
AT&T ID #:

Sprint
Sprint ID# :

MCI

V-SPAN:

Other:

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