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 III

BLOCK 3: Certifications, Signatures and Seal of Notary Public

	I certify that I am authorized to submit this request on behalf of the above-named requester, that I have examined this request and to the best of my knowledge, information and belief, all statements of fact contained herein are true. I am aware that persons making willful false statements on this form can be punished by fine or imprisonment under Title 18 of the United States Code, 18 USC §1001:

	___________________________________________________
	Signature
	_____ / _____ / ______
	Date
	___________________________________________________
	Printed name of authorized person
	___________________________________________________
	Title or position of authorized person
	___________________________________________________
	Title or position of authorized person
	Seal of notary public
	_____ / _____ / ______
	Date Commission Expires

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[ Form III, Block 2: Commencement of Service ]			Return to Appendix C. Recommended Application Forms

This page last updated 8/10/97 (pjh).