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

The State of ____________________ pledges its support for implementing the following systemic technology plan and submits this application for first-year funding under Title III of the Elementary and Secondary Education Act to establish a partnership with the U.S. Department of Education and others in this endeavor.

1. Legal Name of Applicant Agency (State Educational Agency):	2. Employer Identification Number (EIN):
3. Applicant Address (include Zip):	4. Contact Person Name: Position: Telephone: Fax:
5. Status With Respect to Executive Order 12372: ____ Application was made available for review ____ Program was not selected for review	6. Is the applicant delinquent on any Federal debt? ____ No ____ Yes, explanation attached
7. To the best of my knowledge and belief, all data in this application are true and correct. The document has been duly authorized by the governing body of the applicant and the applicant will comply with the attached assurances if the assistance is awarded.
a. Typed Name and Title of Authorized Representative:	b. Telephone Number
c. Signature of Authorized Representative	d. Date

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[Letter to Chief State School Officers]

[Application Instructions]