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 2: Services Ordered


9. Please check off the eligible service(s) requested.
Add an additional list for any requested eligible service not included in the checklist.
Internal connections

    Voice network


    Number of Nodes
¤ 1-20
¤ 21-50
¤ 51-100
¤ 101-250
¤ 251-500
¤ greater than 500


    Other features
¤ Intercom
¤ 1 way
¤ 2 way
¤ Dial in only
¤ Dial out only
¤ Other (specify)
____________________


    Data/LAN, including Intranet


    Speed
¤ 10 mbps or less
¤ greater than 10 mbps


    Number of LANs
¤ 1-2
¤ 3-5
¤ 6-10
¤ 11-20
¤ greater than 20


    Number of Nodes per LAN
¤ 1-20
¤ 21-50
¤ 51-100
¤ 101-250
¤ 251-500
¤ greater than 500


    Number of Facilities/Buildings
¤ 1-2
¤ 3-5
¤ 6-10
¤ 11-20
¤ greater than 20


    Other Features
¤ Other (specify)
____________________


    Video


    Speed
¤ less than 56 kbps
¤ 56-less than 400 kbps
¤ 400-less than 1.6 Mbps
¤ greater than 10 Mbps


    Number of Nodes
¤ 1-20
¤ 21-50
¤ 51-100
¤ 101-250
¤ 251-500
¤ greater than 500


    Number of networks
¤ 1-2
¤ 3-5
¤ 6-10
¤ 11-20
¤ greater than 20


    Other Features
¤ Dedicated
¤ Switched
¤ Other (specify)
____________________


    Transmission Method for Internal Connection(s)
    check all that apply)
¤ wireline
¤ wireless

    External connections


    Voice












¤ Basic telephone:
incoming _____
outgoing _____
extention paths _____
¤ Usage
¤ Toll
¤ Custom features
¤ Paging
¤ Voice mail
¤ Other (specify)
____________________


    Data


    Speed
¤ less than 56 kbps
¤ 56-400 kbs
¤ 400-1.6 Mbs
¤ 1.6-10Mbs
¤ Other (specify)
____________________


    Other Features
¤ Dedicated
¤ Switched
¤ Other (specify)
____________________


    Number of locations
¤ 1-2
¤ 3-5
¤ 6-10
¤ 11-20
¤ greater than 20


    Video


    Speed
¤ less than 56 kbps
¤ 56-400 kbs
¤ 400-1.6 Mbs
¤ 1.6-10 Mbs
¤ Other (specify)
____________________


    Number of locations
¤ 1-2
¤ 3-5
¤ 6-10
¤ 11-20
¤ greater than 20


    Other Features
¤ Dedicated
¤ Full motion
¤ Switched
¤ Compressed rate (specify)
____________________


    Transmission Method for Internal Connection(s)
    check all that apply)
¤ wireline
¤ wireless


    Internet services


    Speed
¤ less than 56 kbps
¤ 56-400 kbs
¤ 400-1.6 Mbs
¤ 1.6-10 Mbs
¤ Other (specify)
____________________


    Number of students (potential e-mail addresses)
¤ 1-20
¤ 21-50
¤ 51-100
¤ 101-250
¤ 251-500
¤ greater than 500


    Service Provider






Name
___________________________________________________
Control Number
___________________________________________________
Date Contract Signed
_____ / _____ / ______
Contract Price
___________________________________________________
a. Single payment __________
b. Estimated recurring payments in current fund year __________
b. Estimated recurring payments in next fund year __________


-###-

[ Form II, Block 1:
Requester Information ]		 Return to Appendix C. Recommended Application Forms [ Form II, Block 3:
Certifications, Signatures
and Seal of Notary Public

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