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1 GE FORM #_ Form Approved December 1968 (Budget Bureau No._) U.So Dep*t of Health, Education & Welfare SECTION I File No._ (leave blank) 1. Name of Applicant (legal, name) APPLICATION FOR FEDERAL GRANT FOR NON¬ COMMERCIAL EDUCATIONAL BROADCAST FACILITIES INSTRUCTIONS Street Address A* This form is to be used only in applying to the Commissioner of Education for a Federal matching grant for the construc¬ tion of a new noncommercial educational broadcast station or to expand an existing station. This form consists of this part', Section I, and the following sections: Section II, Legal Qualifications of Applicant Section III, Population & Enrollment Data Section IV, Program Service of Applicant Section V, Data on Project Equipment Section VI, Financial Data and Assurances Section VII, o£her Assurances B. Before filling out this application, the applicant should familiarize himself with; the Communications Act of 1934, as amended, particularly Title III, Part IV; the printed Regulations and' Instructional Manual relating to Title I of P.L. 90-129; Parts 1, 2, 73, 74 and 17 of the Rules and Regulations of the FCC; and the requirements of 45 CFR Part 80, issued pursuant to Section 601 of the Civil Rights Act of 1964. C. PREPARE FOUR COPIES of this form and all exhibits. Mail two copies to the Director, Educational Broadcasting Facilities Program, U.S. Office of Education, Washington, D.C., 20202; one copy to the Secretary, FCC, Washington, D.C. 20554; and one copy to the State educational broadcasting agency, if any, in the State in which the channel associated with the project is assigned by the FCC. D. This application must include one copy of each appropriate FCC application or authorization as required by the agency for any aspect of the proposed project for which a Federal grant is requested. City ~ State Zip Code 2, Name of Person to whom communications should be sent: Street Address State Zip Code Telephone: Area Code The applicant - is: a public elementary, secondary, or higher education agency _the State ETV or Radio agency a tax supported college or university a nonprofit foundation, corporation, or association __a municipality 4. Under - P«1. 9 87-447T90-129, state the number of grants previously received ; the number of applications currently on file TT^re~any~other Federal grants, which relate to your Broadcast operation, currently being applied for? _Yes No If yes, state the nature of such grant. 6. Has a copy of this application been served on the State ETV/Radio agency? _Yes _No. Have State agencies of other States which fall within the applicants coverage area been notified? Y es _No Has a copy of tlfis application been served on the FCC? Y es N o WORKING DRAFT ONLY—NOR FOR OFFICIAL DISTRIBUTION OR USE. 7. Is FCC authorization required by this proposed project? _Yes _No; is a copy of FCC application(s) attached? _Yes_No. (.Approval <§»f project is contingent upon FCC having granted «ny ssary authorization to .construct nece sary auth roaacast izatu cilit’ Regulations.)