The Next Step

Thank you for contacting eRateProgram, LLC! We will contact you shortly to in order to provide a no cost, no obligation estimate of your E-Rates along with our fees. In order to expediate the process, you are encouraged to fill out and submit the confidential E-Rate information form below. Or, you may download the form here, and fax or email it to our office at 314-395-5882 (fax) or sglickman@erateprogram.com (email). For help completing this form, please call 314-282-3676.

Section I -- School Information

School *			Number of Buildings *
Address *

City *	State *		Zip *
FCC #	NCES #

Contact #1 (Primary decision maker, contact for school information, service providers, plans and accounts)
Name *		Title *
Phone *		Fax *
Email *
Contact #2 (Person responsible for paying invoices and bills)
Name *		Title *
Phone *		Fax *
Email *

Section II -- School Statistics

Total Student Enrollment *

Total Number of Classrooms *

Total Number of Devices with Internet Access *

Do you participate in the National School Lunch Program (Free & Reduced Lunch)?*

Yes

If so, how many students are eligible for Free/Reduced Lunch?

How many students receive financial aid?

Do you use a 3rd party financial aid company to administer financial aid applications
such as FACTS, SSS, PSAS, FAIR, TAD, SMART or administer it internally?*

Yes

If YES, which one?

Section III -- Service Providers and Financial Information

Service Providers

Cost Per Month

Local Phone Provider *

# Lines *

Long Distance Provider *

Cell Phone Provider *

# of Phones

Internet Provider *

Internet Speed *

DSL

T-1

Cable

Speed

Broadband

Speed

Web Hosting Provider

Other Internet Provider(s)

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