
					Rod R. Blagojevich, Governor

IP Video Gateway Reservations

Please fill out the form completely and print a copy for your records.

Gateway Services

Initiator Site Name:

Initiator Site Number:

Conference Initiator Contact Name:

Conference Initiator Telephone:

Conference Initiator E-mail:

Requested Conference Date: (MM/DD/YYYY)

Requested Start Time: (specify AM and PM)

Requested End Time: (specify AM and PM)

Destination Telephone Number:

Destination Site Name:

Comments: