*Pages 1--1 from  22614.xls*
 FCC  Form  470  Approval  by  OMB  3060-  0806 
 Block  1:  Applicant  Address  and  Identifications  1  Name  of  Applicant  (30  characters  max.) 
 2  Funding  Year:  July  1,  _______  through  June  30,  ________  3  Your  Entity  Number  (up  to  10  digits) 
 4a  Street  Address,  P.  O.  Box, 
 or  Route  Number 


 City  State  Zip  Code  _  _  _  _  _  -  _  _  _  _ 
 b  Telephone  Number  (10  digits  +  ext.)  (_  _  _)  _  _  _  -  _  _  _  _  ext.  _  _  _  _  _ 
 c  Fax  Number  (10  digits)  (_  _  _)  _  _  _  -  _  _  _  _ 
 d  E-  mail  Address  (50  characters  max.)  5  Type  of  Applicant  Library 


 Individual  School 
 School  District 
 Consortium 


 6a  Contact  Person's  Name 


 Then  check  the  box  next  to  the  preferred  mode  of  contact.  (At  least  one  box  MUST  be  checked.) 
 b  Street  Address,  P.  O. 
 Box,  or  Route  Number 


 City  State  Zip  Code  _  _  _  _  _  -  _  _  _  _ 
 c  Telephone  Number  (10  digits  +  ext.)  (_  _  _)  _  _  _  -  _  _  _  _  ext.  _  _  _  _  _ 
 d  Fax  Number  (10  digits)  (_  _  _)  _  _  _  -  _  _  _  _ 
 e  E-  mail  Address  (50  characters  max.) 


 Block  2:  Summary  Description  of  Needs  or  Services  Requested  7  This  Form  470  describes  (check  all  that  apply): 


 a 
 b 
 c  Services  for  which  a  new  written  contract  is  sought  for  the  funding  year  in  Item  2. 
 d 


 First,  fill  in  every  item  of  the  Contact  Person's  information  below  that  is  different  from  Item  4,  above. 


 Estimated  Average  Burden  Hours  Per  Response:  4  hours 
 Please  read  instructions  before  beginning  this  application.  (You  can  also  file  online  at  www.  sl.  universalservice.  org) 
 Form  470  Application  #:  ______________________  (To  be  inserted  by  Fund  Administrator) 


 (intermediate  service  agencies,  states,  state  networks,  special  consortia) 
 Applicant's  Form  Identifier:  ___________________  (Create  your  own  code  to  identify  THIS  Form  470) 
 (LEA;  public  or  non-  public  [e.  g.,  diocesan]  local  district  representing  multiple  schools) 


 Schools  and  Libraries  Universal  Service  Description  of  Services  Requested  and  Certification  Form  470 
 (including  library  system,  library  branch,  or  library  consortium  applying  as  a  library) 
 (individual  public  or  non-  public  school) 


 NOTE:  Services  that  are  covered  by  a  signed,  written  contract  executed  pursuant  to  posting  of  a  Form  470  in  a  previous  program  year  OR  a  contract  signed  on/  before  7/  10/  97  and  reported  on  a  Form  470  in  a  previous  year  as  an  existing  contract  do  NOT  require  filing  of  a  Form  470. 
 Tariffed  services  --  telecommunications  services,  purchased  at  regulated  prices,  for  which  the  applicant  has  no  signed,  written  contract.  A  new  Form  470  must  be  filed  for  tariffed  services  for  each  funding  year. 
 Month-  to-  month  services  for  which  the  applicant  has  no  signed,  written  contract.  A  new  Form  470  must  be  filed  for  these  services  for  each  funding  year. 


 A  multi-  year  contract  signed  on  or  before  7/  10/  97  but  for  which  no  Form  470  has  been  filed  in  a  previous  program  year. 


 This  form  is  designed  to  help  you  describe  the  eligible  telecommunications-  related  services  you  seek  so  that  this  data  can  be  posted  on  the  Fund  Administrator  Web  Site  and  interested  service  providers  can  identify  you  as  a  potential  customer  and  compete  to  serve  you. 
 Do  not  write  in  this  area. 


 Page  1  of  6  FCC  Form  470  —  April  2002 
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