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February 6, 2012
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Affiliation Form
If you want your room to be added to our directory, please fill out this form or download the pdf version and fax it back to us : 1-(201) 947 6814.
Adding your room in the directory will increase your visibility and therefore your potential business.

ROOM PHYSICAL ADDRESS :
* Company:  
* Street Address 1 :  
Street Address 2 :  
* City :  
* State :  
* ZIP 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 :  
E-mai :  
CONTACT INFORMATION :
* 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 AND OTHER INFORMATION :
Retail cost per hour :  
Standard cost per hour :
(for VTN members)		  
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 (for VTN members) :  
Taxes (percent) :  
Pricing and other comments :  
Telephone # in Videoconference Room :  
Fax # in Videoconference Room :  
System Manufacturer and Model :  
Software Version :  
Speeds (check all that apply) :  
112 128 224 256 336 384 512 768
H. 320 (ISDN,T1) H.323 (IP)
Technical Comments :  
Network Protocol :  
Primary ISDN # :  
Secondary ISDN # :  
IP Address :  
Room capacity (number of people) :  
Equipment and Room Capacity Comments :  
   

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