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Video Codec Registration Form

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Video Room Name: *

(e.g. Room 124, Conference Room B, Spanish Room 6, etc.)

Location / Agency: *

Address: *

City: *

State: *

ZIP: *

Data Jack Number: *

Room Phone Number: *

Contact Person for Room Scheduling: *

Room Scheduling Phone Number: *

Technical Contact Person: *

Technical Contact Phone Number: *

Manufacturer: *

Model: *

Serial Number: *

MAC Address: *

Password:

DHCP Enabled:

Yes

Remote Monitoring Enabled:

Yes

Scheduled Install Date: *

Vendor: *

Submitted By: *

Email: *

This video unit is a...: *

new addition to the network

replacement for an existing video unit (please explain in the comments box)

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May 17, 2013

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North Dakota Information Technology Department (ITD)