IVDL REQUEST & INFORMATION FORM
Living Historian you are requesting:
Date/Time wanted
Enter the date you would like the videoconference: Enter the time you would like to start the videoconference: Enter the time you would like to end the videoconference:
--mm/dd/yy --hh:mm am/pm --hh:mm am/pm
What is the grade we will be conferencing with?
What is the name of the site we will be conferencing to?
What is the teacher’s name?
What is the teacher’s email address?
What is the teacher’s phone number?
TECHNICAL STUFF
Select one of the following Connection types that you would prefer:
IP - 384Kbps IP - 512Kbps IP - 768Kbps ISDN - 384Kbps ISDN - 512Kbps ISDN - 768Kbps
Enter your IP address or ISDN # in the space provided:
What is the Technical person’s name?
What is the Technical person’s Email address?
Tech’s. Phone Number, in case of an emergency?
BILLING INFORMATION
Purchase Order #
Account Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone Number
Cell Phone
Fax Number