REALCOM COMPANY, LTD. BANGKOK, THAILAND INTERNATIONAL VIDEOCONFERENCE REQUEST FORM Please print this form, complete it, sign it, and fax to +66 2 653-9172 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: Name of Company: ................................ Contact Person: ................................ Address: ........................................ Billing Address:................................. Telephone: ...................................... Fax: ............................................ Realcom Registration number (if known): ......... Request Conference Date: Date: ......................... Time Start: ................... Time Finish: .................. ( Thailand Localtime ) Number of Attendees: .......... Location: [ ] Amari Atrium Hotel [ ] Amari Watergate Hotel [ ] Amari Orchid Resort, Pattaya [ ] German-Thai Chamber of Commerce, Empire Tower [ ] JW Marriott Hotel [ ] Royal Garden Resort & Plaza, Pattaya [ ] Royal Orchid Sheraton [ ] Sofitel Silom Bangkok [ ] Novotel Bangna Country to be connected: Company to be connect: .......................... Contact Person: ................................. Tel.: ................. Fax: .................... Partner Studio Information: Partner Studio: ................................. City: ........................................... Tel. Studio: .................................... Fax Studio: ..................................... Videoconference number: 1 ....................... Videoconference number: 2 ....................... Videoconference number: 3 ....................... Videoconference number: 4 ....................... Videoconference number: 5 ....................... Videoconference number: 6 ....................... Videosystem: .................................... Transmission Rate: [ ] 2 x 56 kbit/s [ ] 2 x 64 kbit/s [ ] 4 x 56 kbit/s [ ] 4 x 64 kbit/s [ ] 6 x 56 kbit/s [ ] 6 x 64 kbit/s Who Starts the Connection: [ ] Realcom Thailand [ ] Opposite Company: Connection Type: [ ] Point-to-Point [ ] Multipoint Multipoint Partner #2 Studio Information: Partner Studio: ................................. City: ........................................... Tel. Studio: .................................... Fax Studio: ..................................... Videoconferencenumber: .......................... Videosystem: .................................... Multipoint Partner #3 Studio Information: Partner Studio: ................................. City: ........................................... Tel. Studio: .................................... Fax Studio: ..................................... Videoconferencenumber: .......................... Videosystem: .................................... Multipoint Partner #4 Studio Information: Partner Studio: ................................. City: ........................................... Tel. Studio: .................................... Fax Studio: ..................................... Videoconferencenumber: .......................... Videosystem: .................................... Payment: Amount: .............. in Cash: ............. Company - Cheque: Bank: ........................................... Branch: ....................... Account number: ................ Date: ................ No Personal Cheques accepted. 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. ACCEPTED AND AGREED BY ..................................... Position: ....................... Place: .......................... Date: ...................