Fillable HVECIVRoomRequestForm-2013-2015 Distributed Employee Information Form

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HVECIVRoomRequestForm-2013-2015 Distributed Employee Information Form

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IF OFF-CAMPUS ORGANIZATION, PLEASE COMPLETE AND SIGN THIS STATEMENT:
Agrees to (1) accept responsibility for payment of fees indicated on the
fee schedule and for any other charges resulting from the organization's use of college facilities; (2) promptly pay for any loss or
damage to College property arising out of or as a result of the organization's use of these facilities (3) abide by the rules and
regulations governing the use of the College facilities; and (4) any changes to this request after the approval has been granted will
result in additional fees being assessed.
Hudson Valley Educational Consortium
Interactive Video Room Request Form
115 South Street | Middletown, NY 10940 | Phone (845) 341-4958 | Fax (845) 341-4382
Academic
Continuing Ed
Other
Consortium
Non-Consortium
Internal
Off-Campus
Contact Name
Dept/Org
Address
City, State Zip
Work Phone Cell Phone
Email
Course Number
Course/Event Title
CIP Code # of Sessions
Start Date End Date Instructor
Address
Organization
Work Phone
Cell Phone
Email
Credit Hours
Contact Hours
Gen Ed Credit?
Yes
No
Fee ($)
M T W R F S
Start Time End Time
Reserve Start Reserve End
Computer
Internet Access for User's Laptop
Smartboard
Plasma TV for Presentation
Document Camera
VHS Videotape Player/Recorder
DVD Player
DVD Recorder
Audio and Video Aux Inputs
Telephone Conferencing
Will you require training in the equipment selected?
Will you need an ITS technician for the event?
Other
No
Yes
No
Yes
Semester
Sullivan
Other
Ulster Newburgh
Rockland
Orange
Interactive Video Connections
HOST CAMPUS
Description
(Event/Course/Catalog)
Today's Date
Event Recording
Audio & Video Conferencing
SPECIAL NEEDS
If you will be using your own
equipment in the room,
please list all items here.
Signature
Date
Yes No
Recurring?
CONTACT INFORMATION
COURSE/EVENT INFORMATION
REQUEST TYPE
EQUIPMENT NEEDS
3/14/13
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HVECIVRoomRequestForm-2013-2015 Distributed Employee Information Form

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Completed 12 February 2020

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