Room/Healthnet Request

New Request

General Information:

Contact Person:
Contact Email:
Phone: Ext:
Department:
Person Using Room:
Purpose of Meeting:
Room # Requested:
Notes:

Number of People Attending In:

Lubbock:
Amarillo:
Dallas:
El Paso:
Abilene:

Special Needs:

Will you need AV equipment:
YesNo
If yes, Equipment Needed:

Broadcast Information:

Will this meeting be broadcast:
Yes
No If yes, Please Select from the List:

Broadcast Originates From: Lubbock
Amarillo
Dallas
El Paso
Abilene

Date(s)	Start Time	End Time

Please only hit Submit once to avoid duplicate submissions.

Once you hit the submit button, an email will automatically be sent to your email address with a reference number for your request. You can use this reference number to assure yourself that the form went through and to check the status of your request to see when approval has been given. All requests should be worked within 48 hours of the request submission. If you do not receive an email with a reference number within five minutes, your request did not complete properly.

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