Non-STAGEnet Connection Testing Request Form

Requesting Institution Information

Date Submitted
Date of Event Test to be completed by
Preferred Test Time(Central Time)

Title of Event Facilitator/ Person Requesting Event
Department Institution/City
Phone E-mail

Host campus contact/site coordinator
Phone E-Mail


Non-STAGEnet Site Information

Name of the Institution City/State/Country
Contact Name E-mail
Contact Phone
Room Name/No. of Testing Site *Room Phone

Type of Equipment

Polycom Tandberg Other
Make Model

Type of Network(check one) H.323 ISDN (if ISDN)Phone

IP Address

Is there a Firewall...??? Yes No

If yes,provide IP address outside firewall:

* If you do not have a phone in the room, please enter "None".

Once you click submit, the request will be forwarded to the IVN Network Technicians. You will recieve the notification for the submitted request via e-mail. You will be contacted by IVN Technician, either by phone or e-mail regarding the set-up for testing.

Back to General Information