|
Institution Name
|
|
|
Address1
|
|
|
Address2
|
|
|
City, State, Zip
|
|
|
Country
|
|
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Phone Number
|
|
|
Fax Number
|
|
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IT Contact
|
|
|
Name
|
|
|
Phone Number
|
|
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Fax Number
|
|
|
Video Site Contact
|
|
|
Name
|
|
|
Phone Number
|
|
|
Fax Number
|
|
|
Alternate Video Site Contact
|
|
Name
|
|
|
Phone Number
|
|
|
Video Conference System Phone Number(s)
|
| |
|
| |
|
| |
|
| |
|
|
Video Conference Room
|
|
Phone Number
|
|
|
Bldg/Room Number
|
|
|
Network Information
|
Select Applicable Transmission Speeds
|
| |
112
(Dual 58 Kbps)
|
| |
128
(Dual 64 Kbps)
|
| |
338
(6 X 56 Kbps)
|
| |
384
(7 X 56 Kbps)
|
| |
384
(6 X 64 Kbps)
|
| |
All
of the above
|
|
IP Address(es)
|
Location
|
IP #
|
| |
|
|
| |
|
|
| |
|
|
|
Video Transmission Carrier
|
|
Dedicated (Internet) |
Switched (ISDN) |
| |
AT&T
|
AT&T
|
| |
MCI
|
MCI
|
| |
Sprint
|
Sprint
|
| |
BellSouth
|
BellSouth
|
| |
Other
(please specify
below) |
Other
(please specify
below) |
| |
|
|
|
Network Access
|
Choose One
|
| |
Dedicated
|
Switched
Access
|
| |
T1
|
LEC
Switched
|
| |
ISDN
PRI
|
ISDN
BRI
|
| |
DDS
|
|
|
Video Conference Equipment Information
|
|
Type
|
|
| |
|
| |
|
|
Equipment Manufacturer
|
|
|
Equipment Model
|
|
|
Equipment Serial Number
|
|
|
Software Version
|
|
|
Video Algorithm
|
|