* 1. Conference Title:

* 2. Contact Name:

* Contact Email:

* Contact Phone (with area code):
Ext.

* Institution/Department:

* Street Address:

* City:
*State: *ZIP:

* 3. Presenter(s) Name(s):

In order to check availability and schedule your program we require the following information:

4. Meeting audio (choose one):

Regular phone audioconferencing
Internet (IP) audioconferencing
IP and phone audioconferencing

* 5. How many audio lines do you need? (if using phone audio):

* 6. Total number of computer connections needed (100, maximum):

* 7. Do you want participants to call in on audio using:

608 bridge number (participant pays long distance) 
800 toll-free bridge number (department pays long distance charges) 
Both

8. For returning customers, please give us your WisLine Web four-digit conference code:

* 9. All conferences are archived in LiveMeeting High Fidelity and LiveMeeting Replay, and are accessible on the web for 365 days at no charge. Would you like a copy of your conference?

 Yes, on CD ($15 charge)
 Yes, file download ($15 charge)
 No, thanks

Options:

If you would like a copy of your conference, please select one of the following options.

LiveMeeting High-Fi (best playback - captures everything that happens in the meeting)
LiveMeeting Replay (best for posting to websites - .wmv format)

* 10. What date(s) are you requesting?

Preferred starting date (MM/DD/YY):
Preferred ending date (MM/DD/YY):

* 11. At what time(s) will your session(s) be held?

Preferred starting time:

Preferred ending time:

* 12. List ALL dates, days, and times requested (Please list dates in MM/DD/YY format):
NOTE: We are closed on State of Wisconsin holidays (New Year's Day, Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Eve, Christmas, New Year's Eve)

13. Exceptions:
List all days or periods of time which your program should NOT be scheduled (i.e., Spring Break dates, exam days, etc.). If not applicable, enter N/A.

* 14. Will you use any UW System campus locations? Select all needed.
*To select multiple sites, use Ctrl + Click (PCs) or Shift + Click (Macs).

UW-Eau Claire UW-Green Bay UW-La Crosse UW-Milwaukee UW-Oshkosh UW-Parkside UW-River Falls UW-Stevens Point UW-Stout UW-Superior UW-Whitewater UW-Extension, The Pyle Center UW-Baraboo/Sauk County UW-Barron County UW-Fond du Lac UW-Fox Valley UW-Manitowoc County UW-Marathon County UW-Marinette County UW-Marshfield/Wood County UW-Richland UW-Rock County UW-Shegoygan UW-Washington County UW-Waukesha County UW Colleges Administrative Office None

15. If you are using The Pyle Center, how many attendees do you anticipate?   

16. Would you like to use the WisLine Web Online Registration System to register your participants?
For more information on the registration system, please visit http://www.uwex.edu/ics/wlweb/registration.htm.

 Yes, please set up my event in the registration system

Please enter your billing information in the appropriate box. We must have billing information before we can schedule your conference. We can accept the following types of payment (Note: This is NOT a secure site. Information you enter may be at risk.). Please check the appropriate type and enter the information requested.

Direct Invoice (State of Wisconsin Gov't, Non-profit, or Customers Outside Wisconsin, only).

Blanket Account (UW customers)

Account Number:

Direct Charge (UW customers)

Fund/Acct/Unit/Div/Dept/Act/Class Code:

Credit Card

We accept Visa, Master Card, and American Express. This is not a secure web site. You will be contacted for your credit card information following receipt of this form.

17. Bill To:
(returning customers may skip this section, unless there is a change in your billing information)

Name:
Institution/Department:
Street Address:
City, State, Zip:
Phone:	- - Ext:
Email:
Tax Exempt Number: (non-profits, only)

18. Are you delivering this course using any other distance technologies (i.e. videoconferencing, Internet, videotape, audio conference, etc.)? If so, please tell us what they are. If not, enter N/A.

19. Is there anything else we need to know about this conference/ program?

* Your name:

* Your email address:

* Confirm your email address:

* Your phone number: