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 I

BLOCK 4: Certifications, Signatures and Seal of Notary Public

I certify that the applicant that I representing satisfies all of the requirements below and will abide by all of the relevant requirements with respect to funding provided under 47 USC §254:

16. The applicant is an eligible entity or includes an eligible entity under 47 USC §254 (h) (4) because it is requesting services for (check all that apply):

¤ A school under the statutory definitions of elementary and secondary schools in the Elementary and Secondary Education Act of 1965, 20 USC §§ 8801 (14) and (25), that does not operate as a for-profit business and does not have an endowment exceeding $50 million.

¤ A library eligible for assistance from a State library administrative agency under the Library services Technology Act of 1996, 20 USC §351(a) (5), that does not operate as a for-profit business, and does not receive funding through an elementary or secondary school, college or university.

17. ¤ These services will be used solely for educational purposes and will not be sold, resold or transferred in consideration for money or any other thing of value.

18. ¤ (Must check if applicant is applying for services other than basic telephone service.) The applicant recognizes that support under this program is conditional upon the school(s) or library(ies) receiving requested services securing access to all of the resources, including computers, training, software, maintenance, electrical connections and security, necessary to use effectively the services purchased.

19. ¤ (Must check if applicant is applying for services other than basic telephone service.) Each school and/or library that will receive eligible services under this application is covered by a technology plan meeting the requirements of paragraphs 573-574 of the FCC's E-Rate Ruling. All such plan(s) have been subject to independent approval in accordance with those paragraphs, and this request for services is consistent with the plan(s). Funds have been budgeted to purchase the telecommunications and information services being ordered. The specific technology plans and their approvers' identities and dates of approval are available in the applicant's work papers.

20. ¤ No related services or facilities that are INELIGIBLE for support are included in the services requested.

21. ¤ If the applicant is seeking to procure eligible services for multiple users, a list of all prospective users, giving for each, its name, address, contact person, telephone number, E-mail address, and website if any, must be available in work papers for audit. In addition, indicate in these work papers whether each user is eligible for universal service support.

22. ¤ All applicable State and local laws regarding procurement processes have been followed for all eligible services for which support is requested under this application.


	I certify that the applicant that I representing satisfies all of the requirements below and will abide by all of the relevant requirements with respect to funding provided under 47 USC §254:
16.	The applicant is an eligible entity or includes an eligible entity under 47 USC §254 (h) (4) because it is requesting services for (check all that apply):


	¤	A school under the statutory definitions of elementary and secondary schools in the Elementary and Secondary Education Act of 1965, 20 USC §§ 8801 (14) and (25), that does not operate as a for-profit business and does not have an endowment exceeding $50 million.
	¤	A library eligible for assistance from a State library administrative agency under the Library services Technology Act of 1996, 20 USC §351(a) (5), that does not operate as a for-profit business, and does not receive funding through an elementary or secondary school, college or university.


17.	¤	These services will be used solely for educational purposes and will not be sold, resold or transferred in consideration for money or any other thing of value.
18.	¤	(Must check if applicant is applying for services other than basic telephone service.) The applicant recognizes that support under this program is conditional upon the school(s) or library(ies) receiving requested services securing access to all of the resources, including computers, training, software, maintenance, electrical connections and security, necessary to use effectively the services purchased.
19.	¤	(Must check if applicant is applying for services other than basic telephone service.) Each school and/or library that will receive eligible services under this application is covered by a technology plan meeting the requirements of paragraphs 573-574 of the FCC's E-Rate Ruling. All such plan(s) have been subject to independent approval in accordance with those paragraphs, and this request for services is consistent with the plan(s). Funds have been budgeted to purchase the telecommunications and information services being ordered. The specific technology plans and their approvers' identities and dates of approval are available in the applicant's work papers.
20.	¤	No related services or facilities that are INELIGIBLE for support are included in the services requested.
21.	¤	If the applicant is seeking to procure eligible services for multiple users, a list of all prospective users, giving for each, its name, address, contact person, telephone number, E-mail address, and website if any, must be available in work papers for audit. In addition, indicate in these work papers whether each user is eligible for universal service support.
22.	¤	All applicable State and local laws regarding procurement processes have been followed for all eligible services for which support is requested under this application.

I certify that I am authorized to submit this application on behalf of the above-named applicant, that I have examined this application 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.


	I certify that I am authorized to submit this application on behalf of the above-named applicant, that I have examined this application 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


	___________________________________________________
	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 I, Block 3:
Services Requested [ Form II, Block 1:
Requester Information


[ Form I, Block 3: Services Requested				[ Form II, Block 1: Requester Information

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