Non-STAGEnet Connection Testing Request Form

Testing Requesting Institution Information

Date Submitted
Title
Test Requested by Institution
Phone E-mail
Date of Planned Event   Click

Time(USA-Central Time)

International- Greenwich


Non-STAGEnet Institution Information

Name of the Institution City/State/Country
Contact Name Phone
Room Name/No. of Testing Site Room Phone

Type of Equipment

Polycom Tandberg Other
Make Model

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

IP Address

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

If yes,provide IP address outside firewall:

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