FCC Form 470 Approval by OMB

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1 USAC 470 Appliction FCC Form 470 Pge 1 of 6 Approvl y OMB Schools nd Lirries Universl Service Description of Services Requested nd Certifiction Form 470 Estimted Averge Burden Hours per Response: 3 hours This form is designed to help you descrie the eligile services you seek so tht this dt cn e posted on the Fund Administrtor Internet Site nd interested service providers cn identify you s potentil customer nd compete to serve you. Plese red instructions efore eginning this form. (You cn lso file online t Form 470 Appliction Numer: Appliction Sttus: INCOMPLETE Allowle Contrct Dte: Block 1: Applicnt Address nd Informtion 1 Nme of Applicnt: ALPHA KAPPA ALPHA HEAD START Posting Dte: Certifiction Received Dte: 2 Funding Yer: 2013 (Funding yers run from July 1 through the following June 30) 3 4 Street Address, P.O.Box, or Route Numer: 620 WEST MADISON AVE City: EL CAJON Stte: CA Zip Code: Telephone Numer: (619) c Fx Numer: (617) Eligile Entities Tht Will Receive Services: Check the ONE choice in 5 tht est descries the eligile entities tht will receive the services descried in this form. You will then list in Item 15 the entity/entities tht will py the ills for these services. Individul School (individul pulic or non-pulic school) School District (LEA; pulic or non-pulic [e.g., diocesn] locl district representing multiple schools) Lirry (including lirry system, lirry outlet/rnch or lirry consortium s definedunder LSTA) Consortium (intermedite service gencies, sttes, stte networks, consorti of schools nd/or lirries) Sttewide ppliction for (enter 2-letter stte code) representing (check ll tht pply) All pulic schools/districts in the stte All non-pulic schools in the stte All lirries in the stte 5 Recipient(s) of Services - Check ll tht pply: Privte Pulic Chrter Tril Hed Strt Stte Agency 5c Numer of eligile entities for which services re sought: 16 Block 1: Applicnt Address nd Informtion (continued) 6 Contct Person's Nme: Pul J. Higginson If the Contct Person s Street Address is the sme s Item 4 ove, check here. If not, complete Item 6. 6 Street Address, P.O.Box, or Route Numer: NOTE: USAC will use this ddress to mil correspondence 620 WEST MADISON AVE City: EL CAJON Stte: CA Zip Code: Check the ox next to your preferred mode of contct nd provide your contct informtion. One ox MUST e checked nd n entry provided. 6c Telephone Numer:(619) d Fx Numer:(617) e E-Mil Address:PHigginson@khedstrt.org Re-enter E-mil Address:PHigginson@khedstrt.org If consultnt is ssisting you with your ppliction process, plese complete Item 7 elow: 7 Consultnt Nme: Skip Shrp Nme of Consultnt s Employer: Tech Msters Consultnt s Street Address: Crmel Mountin Rd, Ste City: Sn Diego Stte: CA Zip Code: Consultnt s Telephone Numer: (858) Ext. Consultnt s Fx Numer: (858) Consultnt s E-mil Address: info@the-techmsters.com Re-enter E-mil Address: info@the-techmsters.com Consultnt Registrtion Numer:

2 USAC 470 Appliction Contct Person: Pul J. Higginson Phone Numer: (619) Block 2: Summry Description of Needs or Services Requested 8 Telecommuniction Services If you check YES to indicte you hve Request for Proposls (RFP) tht specifies the services you re seeking, your RFP must e ville to ll interested idders for t lest 28 dys. If your RFP is not ville to ll interested idders, or if you check NO nd you hve or intend to hve n RFP, you risk denil of your funding requests. YES, I hve relesed or intend to relese n RFP for these services. It is ville or will ecome ville on the Internet t: or vi (check one) the contct person in Item 6 or the contct person listed in Item 12 Pge 2 of 6 NO, I hve not relesed nd do not intend to relese n RFP for these services. Service Quntity nd/or Cpcity Digitl Trnsmission Service Interconnect 14 sites t 3, 5, 10 or more Mps Cell phones with undled Internet Approximtely 14 POTS, Usge, Long Distnce, DIDs Approx telephones t 14 sites PRI Approx 1 Functionl Equivlent of ove All sites 9 Internet Access If you check YES to indicte you hve Request for Proposls (RFP) tht specifies the services you re seeking, your RFP must e ville to ll interested idders for t lest 28 dys. If your RFP is not ville to ll interested idders, or if you check NO nd you hve or intend to hve n RFP, you risk denil of your funding requests. YES, I hve relesed or intend to relese n RFP for these services. It is ville or will ecome ville on the Internet t: or vi (check one) the contct person in Item 6 or the contct person listed in Item 12 NO, I hve not relesed nd do not intend to relese n RFP for these services. Whether you check YES or NO, you must list elow the Internet Access services you seek. Specify ech service (e.g., monthly Internet service) nd quntity nd/or cpcity (e.g., for 500 users). Service Quntity nd/or Cpcity We Hosting We-site hosting services Internet Access 14 sites Cell phone service with undled Internet Approximtely 14 users

3 USAC 470 Appliction Contct Person: Pul J. Higginson Phone Numer: (619) Internl Connections Other Thn Bsic Mintennce If you check YES to indicte you hve Request for Proposls (RFP) tht specifies the services you re seeking, your RFP must e ville to ll interested idders for t lest 28 dys. If your RFP is not ville to ll interested idders, or if you check NO nd you hve or intend to hve n RFP, you risk denil of your funding requests. YES, I hve relesed or intend to relese n RFP for these services. It is ville or will ecome ville on the Internet t: or vi (check one) the contct person in Item 6 or the contct person listed in Item 12 Pge 3 of 6 NO, I hve not relesed nd do not intend to relese n RFP for these services. Whether you check YES or NO, you must list elow the Internl Connections services you seek. Specify ech service (e.g., router,hu nd cling) nd quntity nd/or cpcity (e.g., connecting 1 clssroom of 30 students). 11 Bsic Mintennce of Internl Connections If you check YES to indicte you hve Request for Proposls (RFP) tht specifies the services you re seeking, your RFP must e ville to ll interested idders for t lest 28 dys. If your RFP is not ville to ll interested idders, or if you check NO nd you hve or intend to hve n RFP, you risk denil of your funding requests. YES, I hve relesed or intend to relese n RFP for these services. It is ville or will ecome ville on the Internet t: or vi (check one) the contct person in Item 6 or the contct person listed in Item 12 NO, I hve not relesed nd do not intend to relese n RFP for these services. Whether you check YES or NO, you must list elow the Bsic Mintennce services you seek. Specify ech service (e.g., sic mintennce of routers) nd quntity nd/or cpcity (e.g., for 10 routers).

4 USAC 470 Appliction Contct Person: Pul J. Higginson Phone Numer: (619) (Optionl) Plese nme the person on your stff or project who cn provide dditionl technicl detils or nswer specific questions from service providers out the services you re seeking. This person does not need to e the contct person(s) listed in Item 6 nor the Authorized Person who signs this form. Nme: Pul Higginson Title: Director Informtion Technology Telephone Numer: (619) Fx Numer: Emil Address: phigginson@khedstrt.org Re-enter E-mil Address: phigginson@khedstrt.org Pge 4 of 6 13 Check this ox if there re ny restrictions imposed y stte or locl lws or regultions on how or when service providers my contct you or on other idding procedures. Plese descrie elow ny such restrictions or procedures nd/or provide n Internet ddress where they re posted nd contct nme nd telephone numer. Check this ox if no stte nd locl procurement/competitive idding requirements pply to the procurement of services sought on this Form 470. If you re requesting services for funding yer for which Form 470 cnnot yet e filed online, include tht informtion here. Emil Pul Higginson for dditionl informtion Block 3: 14. [Reserved] Contct Person: Pul J. Higginson Contct Phone Numer: (619) Block 4: Recipients of Service 15 Billed Entities List the entity/entities tht will e pying the ills directly to the provider for the services requested in this form. These re known s Billed Entities. At lest one line of this item must e completed. If Billed Entity cited on your Form 471 is not listed elow, funding my e denied for the funding requests ssocited with this Form 470. Attch dditionl pges if needed. Entity Numer Entity Nme ALPHA KAPPA ALPHA HEAD START Contct Person: Pul J. Higginson Contct Phone Numer: (619) Block 5: Certifictions nd Signture 16 I certify tht the pplicnt includes: (Check one or oth.) schools under the sttutory definitions of elementry nd secondry schools found in the No Child Left Behind Act of 2001, 20 U.S.C (18) nd (38), tht do not operte s for-profit usinesses, nd do not hve endowments exceeding $50 million; nd/or lirries or lirry consorti eligile for ssistnce from Stte lirry dministrtive gency under the Lirry Services nd Technology Act of 1996 tht do not operte s for-profit usinesses nd whose udgets re completely seprte from ny schools (including, ut not limited to elementry nd secondry schools, colleges, nd universities). I certify tht, if required y Commission rules, ll of the individul schools nd lirries receiving services under this form re covered y technology plns tht do or will cover ll 12 months of the funding yer, nd tht hve een or will e pproved y stte or other uthorized ody, or n SLD-certified technology pln pprover, prior to the commencement of service. Or I certify tht no technology pln is required y Commission rules. I certify tht I will post my Form 470 nd (if pplicle) mke my RFP ville for t lest 28 dys efore considering ll ids received nd selecting service provider. I certify tht ll ids sumitted will e crefully considered nd the id selected will e for the most cost-effective service or equipment offering, with price eing the primry fctor, nd will e the most cost-effective mens of meeting eductionl needs nd technology pln gols. I certify tht I will retin required documents for period of t lest five yers fter the lst dy of service delivered. I certify tht I will retin ll documents necessry to demonstrte complince with the sttute nd Commission rules regrding the form for, receipt of, nd delivery of services receiving schools nd lirries discounts. I cknowledge tht I my e udited pursunt to prticiption in the schools nd lirries progrm. I certify tht the services the pplicnt purchses t discounts provided y 47 U.S.C. 254 will e used primrily for eductionl purposes nd will not e sold, resold or trnsferred in considertion for money or ny other thing of vlue, except s permitted y the Commission s rules t 47 C.F.R , Additionlly, I certify tht the entity or entities listed on this form hve not received nything of vlue or promise of nything of vlue, other thn services nd equipment sought y mens of this form, from the service provider, or ny representtive or gent thereof or ny consultnt in connection with this request for services. I cknowledge tht support under this support mechnism is conditionl upon the school(s) nd/or lirry(ies) I represent securing ccess, seprtely or through this progrm, to ll of the resources, including computers, trining, softwre, internl connections, mintennce, nd electricl cpcity necessry to use the services purchsed effectively. I recognize tht some of the forementioned resources re not eligile for support. I certify tht I hve considered wht finncil resources should e ville to cover these costs. I certify tht I m uthorized to procure eligile services for the eligile entity(ies). I certify tht I m uthorized to sumit this request on ehlf of the eligile entity (ies) listed on this form, tht I hve exmined this request, nd to the est of my knowledge, informtion, nd elief, ll sttements of fct contined herein re true. I certify tht I hve reviewed ll pplicle FCC, stte, nd locl procurement/competitive idding requirements nd tht I hve complied with them. I cknowledge tht persons willfully mking flse sttements on this form cn e punished y fine or forfeiture, under the Communictions Act, 47 U.S.C. 502, 503(), or fine or imprisonment under Title 18 of the United Sttes Code, 18 U.S.C I cknowledge tht FCC rules provide tht persons who hve een convicted of criminl violtions or held civilly lile for certin cts rising from their prticiption in the schools nd lirries support mechnism re suject to suspension nd derment from the progrm. Contct Person: Pul J. Higginson Contct Phone Numer: (619) Signture of uthorized person: 26 Dte: 27 Printed nme of uthorized person: Pul Higginson 27 Title or position of uthorized person: Director Informtion Technology

5 USAC 470 Appliction Pge 5 of 6 Check here if the consultnt in Item 7 is the Authorized Person. 27c Street Address, P.O. Box, Route Numer, City, Stte, Zip Code: 620 W. Mdison Ave City: El Cjon Stte: CA Zip Code: d Telephone Numer of Authorized Person: (619) Ext e Fx Numer of Authorized Person: 27f E-mil Address of Authorized Person: Re-enter E-mil Address: 27g Nme of Authorized Person's Employer: AKA Hed Strt Service provider involvement with preprtion or certifiction of Form 470 cn tint the competitive idding process nd result in the denil of funding requests. For more informtion, refer to the Schools nd Lirries re of the USAC we site t or cll the SLD Client Service Bureu t

6 USAC 470 Appliction Contct Person: Pul J. Higginson Phone Numer: (619) N TICE: In ccordnce with Section of the Federl Communictions Commission s rules, certin schools nd lirries ordering services tht re eligile for nd seeking universl service discounts must file this Description of Services Requested nd Certifiction Form (FCC Form 470) with the Universl Service Administrtor. 47 C.F.R (). The collection of informtion stems from the Commission s uthority under Section 254 of the Communictions Act of 1934, s mended. 47 U.S.C The dt in the report will e used to ensure tht schools nd lirries comply with the competitive idding requirement contined in 47 C.F.R Schools nd lirries must file this form themselves or s prt of consortium. An gency my not conduct or sponsor, nd person is not required to respond to, collection of informtion unless it displys currently vlid OMB control numer. The FCC is uthorized under the Communictions Act of 1934, s mended, to collect the informtion we request in this form. We will use the informtion you provide to determine whether pproving this ppliction is in the pulic interest. If we elieve there my e violtion or potentil violtion of ny pplicle sttute, regultion, rule or order, your ppliction my e referred to the Federl, stte, or locl gency responsile for investigting, prosecuting, enforcing, or implementing the sttute, rule, regultion or order. In certin cses, the informtion in your ppliction my e disclosed to the Deprtment of Justice or court or djudictive ody when () the FCC; or () ny employee of the FCC; or (c) the United Sttes Government is prty of proceeding efore the ody or hs n interest in the proceeding. In ddition, informtion provided in or sumitted with this form or in response to susequent inquiries my lso e suject to disclosure consistent with the Communictions Act of 1934, FCC regultions, the Freedom of Informtion Act, 5 U.S.C. 552, or other pplicle lw. If you owe pst due det to the federl government, the informtion you provide my lso e disclosed to the Deprtment of the Tresury Finncil Mngement Service, other Federl gencies nd/or your employer to offset your slry, IRS tx refund or other pyments to collect tht det. The FCC my lso provide the informtion to these gencies through the mtching of computer records when uthorized. If you do not provide the informtion we request on the form, the FCC my dely processing of your ppliction or my return your form without ction. The foregoing Notice is required y the Pperwork Reduction Act of 1995, Pu. L. No , 44 U.S.C. 3501, et seq. Pge 6 of 6 Pulic reporting urden for this collection of informtion is estimted to verge 3 hours per response, including the time for reviewing instructions, serching existing dt sources, gthering nd mintining the dt needed, completing, nd reviewing the collection of informtion. Send comments regrding this urden estimte or ny other spect of this collection of informtion, including suggestions for reducing the reporting urden to the Federl Communictions Commission, Performnce Evlution nd Records Mngement, Wshington, DC Plese sumit this form to: SLD-Form 470 P.. Bo 7026 Lwrence, nss For express delivery services or U.S. Postl Service, Return Receipt Requested, mil this form to: SLD Forms ATTN: SLD Form reenwy Drive Lwrence, nss FCC Form 470 Octoer 2010

FCC Form 470 Approval by OMB

FCC Form 470 Approval by OMB FCC Form 470 Approval y OMB 3060 0806 Schools and Liraries Universal Service Description of Services Requested and Certification Form 470 Estimated Average Burden Hours per Response: 3 hours This form