REALCOM International Videoconference Reservation Form

International Videoconference
Request Form

VIDEOCONFERENCE CONTACT
(Videoconference will be provided 24 hours by request)

TELEPHONE: +66 2 653 9171
FAX: +66 2 653 9172

- TYPE OF REQUEST -
Quotation
Reservation

- CUSTOMER INFORMATION -
Your Name

Your E-mail Address

Company Name:

Today's Date:

Your Mail Address:

Your Billing Address (if different):

Your Telephone Number:

Your Fax Number:

Your Registration Number (for previous REALCOM^® customer):

- VIDEOCONFERENCE INFORMATION -
Conference Date:

Conference Start Time (Bangkok local time):

Conference Finish Time (Bangkok local time):

Number of Attendees:

Conference Location:
Amari Atrium Hotel
Amari Watergate Hotel
Amari Orchid Resort, Pattaya
German-Thai Chamber of Commerce, Empire Tower
JW Marriott Hotel
Novotel Bangna
Royal Garden Resort & Plaza, Pattaya
Royal Orchid Sheraton
Sofitel Silom Bangkok

-TARGET INFORMATION -
Target Company to be connected:

Contact Person at target company:

Contact telephone number:

Contact fax number:

- PARTNER STUDIO INFORMATION -
Partner Studio Name:

Partner Studio City:

Partner Studio Telephone Number:

Partner Studio Fax Number:

Partner Studio E-mail:

Partner Studio Videoconference Number: 1

Partner Studio Videoconference Number: 2

Partner Studio Videoconference Number: 3

Partner Studio Videoconference Number: 4

Partner Studio Videoconference Number: 5

Partner Studio Videoconference Number: 6

Partner Studio Transmission Rate:

2x56 kilobits/second.
2x64 kilobits/second.

4x56 kilobits/second.
4x64 kilobits/second.

6x56 kilobits/second.
6x64 kilobits/second.

Connection Type:
Point-to-Point
Multipoint
Who starts the connection:
Bangkok site
Opposite site

- MULTIPOINT PARTNER STUDIO #2 INFORMATION -
Partner #2 Studio Name:

Partner #2 Studio City:

Partner #2 Studio Telephone Number:

Partner #2 Studio Fax Number:

Partner #2 Studio E-mail:

Partner #2 Studio Videoconference Number:

- MULTIPOINT PARTNER STUDIO #3 INFORMATION -
Partner #3 Studio Name:

Partner #3 Studio City:

Partner #3 Studio Telephone Number:

Partner #3 Studio Fax Number:

Partner #3 Studio E-mail:

Partner #3 Studio Videoconference Number:

- MULTIPOINT PARTNER STUDIO #4 INFORMATION -
Partner #4 Studio Name:

Partner #4 Studio City:

Partner #4 Studio Telephone Number:

Partner #4 Studio Fax Number:

Partner #4 Studio E-mail:

Partner #4 Studio Videoconference Number:

- METHOD OF PAYMENT -
Note: no personal checks are accepted.
Cash Deposit Amount:

Company Cheque Deposit Amount:

Company Cheque Bank Name:

Company Cheque Bank Branch:

Company Cheque Account Number:

Company Cheque Bank Date:

- TERMS OF SERVICE -
WE HEREBY APPLY FOR THE INTERNATIONAL VIDEOCONFERENCE SERVICE AND UNDERSTAND THAT REALCOM^® CO., LTD. WILL PROVIDE THE SERVICE AND FACILITY UNDER THE REGULATION OF CAT VIDEOCONFERENCE SERVICE AND IN ACCORDANCE WITH THE REALCOM^® CO., LTD. TERMS AND CONDITIONS. WE CONFIRM THIS RESERVATION FORM TO THE ABOVE CHARGES.
The above terms are accepted.
The above terms are rejected.
Accepted and agreed by (enter name):

Position/Title of Acceptor:

Place:

Date:

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International Videoconference Request Form

International Videoconference
Request Form