Merced — MSC-VC-001

Source: https://www.merced.courts.ca.gov/system/files/msc-vc-001-video-conference-request-form-rev-712018.pdf

MSC-VC-001

VIDEO CONFERENCE Superior Court of California REQUEST FORM County of Merced

Hearing Information

Date: Time: Location:
Case#: Case name:

Requestors Contact

Name
Street Address
City, State, ZIP
Work Phone
Cell Phone
E-Mail Address

Technical Contact

Name
Street Address
City, State ZIP
Work Phone
Cell Phone
E-Mail Address
Availability for Testing Morning Afternoon Evening

Special Considerations

Summarize any circumstances you feel may impact the ability to conduct a successful test

Agreement and Signature

By submitting this form, I affirm that the facts rthset infoit are true and complete. I understand that any
false statements, omissions, or other misrepresentations made by me on this form may result in the
forfeit of my deposit.

Name (printed)
SIGN
Signature

Date

Functionality (for Court use only)

The test was conducted on with the following results:
Successful Unsuccessful

For Mandatory Use Page 1 of 1 MSC-VC-001 [Rev. July 1, 2018]