Skip navigation

Proximity Affiliate Form


Online Chat with an ACT Conferencing agent

Affiliate Sign-Up Form

Thank you for filling out our room information form to become an ACT Proximity Affiliate! Please complete as thoroughly as possible. We will review your information and get in touch with you shortly.

Room Physical Address:
Company:
Street Address 1:
Street Address 2:
City:
State:
Postal Code:
Country:
Phone:
Fax:

Mailing Address:
(if different from physical address)
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
Country:
Phone:
Fax:
Website:
Email Address:
Reservation Contact:
Phone:
Fax:
Email:
Room Coordinator:
Phone:
Fax:
Email:
Please supply us with directions to your location.
Feel free to send a map as well for attendees use.

Rate Information:
Retail cost per hour:
Standard cost per hour:
(charge to ACT Proximity)
Regular Business hours when standard cost applies:
Is your room available
outside business hours?		 Yes
No

Please indicate days when
your room is NOT available:

M
T
W
Th
F

Sa
Su 		     

After hours availability:
From:

To:
After hours retail cost per hour:
After hours cost per hour:
(charge to ACT Proximity)
Taxes (percent)

Pricing and other comments:

Technical Information:
Telephone # in Videoconference Room:
Fax # in Videoconference Room:
System
Manufacturer
and Model:
Software Version:
Speeds (check all that apply):

112 224 336
128 256 384
512 768

H. 320 (ISDN,T1) H.323 (IP)

Technical comments:
Network Protocol: ISDN
Switched 56
IP (Internet Protocol)
Long Distance Carrier:
Does your system have an IMUX? Yes
No
Make/Model:

Video Dial-Up Numbers:
Primary ISDN #:
Secondary ISDN #:
IP Address:


Video dial-up number comments:

Equipment:
(check all that you have available, and include pricing if available)

Document Camera Cost:

Auxiliary Camera Cost:

Electronic Whiteboard Cost:

VCR Cost:

Scan Converter Cost:

Large Display (>30")  

Dual Monitors  

Video Slide Projector Cost:

Audio Only Interface Cost:

  Capacity (number of people):
 
Equipment and room capacity comments:

 

Bridge Information:
(please indicate those that you are registered with)

AT&T, ID #:

Sprint, ID#:

MCI

V-SPAN:

Other: