Center for Extended and Distance Education

Contact Us

Austin Peay State University
McReynolds Building
Box 4678
Clarksville, TN 37044
Tel (931) 221-7816
Fax (931) 221-7748
exted@apsu.edu

Video Conference Request Form

Contact Name: *

Office Phone: *

Format: (xxx) xxx-xxxx

Company/Firm: *

Office Fax:

Format: (xxx) xxx-xxxx

Contact Email: *

Name of Conference: *

Requested Date: *

Start Time: *

End Time: *

Time Zone: *

Number of People: *

Purpose: *

(e.g., interview, deposition, etc.)

Video Conference Site: *

Please confirm with APSU representative for room location.

Please list contact information by site. If you have multiple sites, we must have contact information for each site.

Contact Name, Site 1:

Contact Email, Site 1:

Office Phone, Site 1:

Format: (xxx) xxx-xxxx

Office Fax, Site 1:

Format: (xxx) xxx-xxxx

Street Address, Site 1:

City:

State:

Zip:

IP Number, Site 1:

Example: 25.34.23.100

Contact Name, Site 2:

Contact Email, Site 2:

Office Phone, Site 2:

Format: (xxx) xxx-xxxx

Office Fax, Site 2:

Format: (xxx) xxx-xxxx

Street Address, Site 2:

City, Site 2:

State, Site 2:

Zip, Site 2:

IP Number, Site 2:

Example: 25.34.23.100

Billing Information

Billing Contact Name: *

Billing Office Phone: *

Format: (xxx) xxx-xxxx

Billing Office Fax:

Format: (xxx) xxx-xxxx

Billing Company/Firm: *

Billing Contact Email: *

Billing Address: *

Billing City: *

Billing State: *

Billing Zip: *

Method of Payment: *

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