Archived: Report to FCC by E-rate Implementation Working Group

A r c h i v e d I n f o r m a t i o n

APPENDIX C

Recommended Application Forms

Schools and Libraries Universal Service Fund

Application for Eligible Services

FCC Form II

BLOCK 1: Requester Information

1. Name of Requester

___________________________________________________

2. Requester Control Number

___________________________________________________

3. Application Control Number

___________________________________________________

4. Complete Mailing Address of Applicant

___________________________________________________

___________________________________________________

City State Zip Code

___________________________________________________

Website URL (if available)

___________________________________________________

Telephone Number Fax Number E-mail Address

5. Contact Person's Name

___________________________________________________

Mailing Address (if different from above)

___________________________________________________

___________________________________________________

City State Zip Code

___________________________________________________

Telephone Number Fax Number E-mail Address

6. This form is (check one)

¤ An original submission ¤ a revised submission
(enter application control number for previous submission, if available;
otherwise, enter the date)

7. ¤ discounts on newly contracted services

¤ discounts in second or later year of long-term contract

¤ pro forma request by applicant for multiple schools and/or libraries that will be billed separately and file their own funding requests

¤ separate billing on contract for which pro forma aggregate request previously filed
(enter previous funding request number) __________

¤ disconnect or terminate services

7. Percentage discount for which requester is eligible. The discount must be calculated using the requester's choice of the appropriate methodologies listed in the instructions. The requester certifies that this discount rate has been calculated in accordance with the instructions to this form. These calculations are available in the requester's work papers. The requester is eligible for a discount of _____ percent.


1.	Name of Requester
	___________________________________________________
2.	Requester Control Number
	___________________________________________________
3.	Application Control Number
	___________________________________________________


4.	Complete Mailing Address of Applicant


	___________________________________________________
	___________________________________________________


	City	State	Zip Code


	___________________________________________________
	Website URL (if available)


	___________________________________________________


	Telephone Number	Fax Number	E-mail Address


5.	Contact Person's Name
	___________________________________________________
	Mailing Address (if different from above)
	___________________________________________________
	___________________________________________________


	City	State	Zip Code


	___________________________________________________


	Telephone Number	Fax Number	E-mail Address


6.	This form is (check one)
	¤	An original submission	¤	a revised submission (enter application control number for previous submission, if available; otherwise, enter the date)


7.	¤	discounts on newly contracted services
	¤	discounts in second or later year of long-term contract
	¤	pro forma request by applicant for multiple schools and/or libraries that will be billed separately and file their own funding requests
	¤	separate billing on contract for which pro forma aggregate request previously filed (enter previous funding request number) __________
	¤	disconnect or terminate services


7.	Percentage discount for which requester is eligible. The discount must be calculated using the requester's choice of the appropriate methodologies listed in the instructions. The requester certifies that this discount rate has been calculated in accordance with the instructions to this form. These calculations are available in the requester's work papers. The requester is eligible for a discount of _____ percent.

-###-

[ Form I, Block 4:
Certifications, Signatures
and Seal of Notary Public [ Form II, Block 2:
Services Ordered


[ Form I, Block 4: Certifications, Signatures and Seal of Notary Public				[ Form II, Block 2: Services Ordered

This page last updated February 8, 1999 (saw).