Satellite Application Form

Broadband Satellite Grant

Application Submission to Rural Utilities Service (RUS)

General Application Information Form

1. Applicant Information

1-A. Name, Address, and Contact Information of Applicant

Legal Business Name of Organization:

Title:

Full Name of Primary Point of Contact:

Street 1:

Street 2:

City:

County:

State:

Province:

Country:

Zip/Postal Code:

Email Address:

Telephone Number:

Fax Number:

1-B. Required Identification Numbers of Applicant

Employer/Taxpayer Identification Number (EIN/TIN):

Organizational (DUNS):

CCR (CAGE) Number:

Catalog of Federal Domestic Assistance Number:

1-C. Name and Contact Information of Additional Project Contact

Organization:

Full Name:

Project Role:

Email Address:

Telephone:

1-D. Type of Organization

Please classify your organization. (Note: If there are multiple organizations involved in the project, designate the lead applicant that would enter into a Grant agreement with the Agency and assume operational and financial responsibility should an award be made).

Local, State, or Other Government Entity

• State or State Agency

• Political subdivision of a State, including Local or County Government

• District of Columbia

• Territory or Possession of the United States

• Indian Tribe

Not for Profit Entity

• Non-Profit Corporation

• Non-Profit Foundation

• Non-Profit Institution

• Non-Profit Association

For Profit Entity

• For-Profit Corporation or Limited Liability Company

Other

• Cooperative or Mutual

• Native Hawaiian organization

• Please identify any others: ________________

1-E. Type of Eligible Entity

Please classify your entity type.

Satellite Projects

• A satellite Internet Service Provider (ISP)

• A reseller of satellite ISP service

• A distributor or dealer of satellite ISP service

• A consortium of one of the above eligible entities, except for a consortium of more than one ISP

1-F. Current Status of Applicant

Is the applicant a start-up company?

Yes No

(If “Yes”, provide the name of the entity with controlling interest) ________________________________

Is the applicant a subsidiary?

Yes No

(If “Yes”, provide the legal name of the parent company) _______________________________________

1-G. Applicant Federal Debt Delinquency Explanation

Is the Applicant Delinquent On Any Federal Debt?

Yes No

(If “Yes”, provide an explanation.) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Co-Applicant Name and Contact Information

Please list any additional co-applicants if applicable. If listing more than one co-applicant, please include additional co-applicant information as an attachment. (Attachment A)

Organization:

Full Name:

Project Role:

Email Address:

Telephone:

3. Project Description

Project Title:

Project Description:

Provide three or four sentences that most concisely describe the proposed project. The description of the project will be made public consistent with the requirements of the Recovery Act. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How many jobs will be created or saved from this project: _______________

4. Project Region(s)

Please select the region(s) for which the applicant is seeking funding:

Region 1	Region 3	Region 5	Region 7
Region 2	Region 4	Region 6	Region 8

• National – Select all regions (listed below) for which the applicant is seeking funding in its National Application:

Region 1	Region 3	Region 5	Region 7
Region 2	Region 4	Region 6	Region 8

5. Congressional District

List the Congressional District of the Applicant’s headquarters: __________

(List the state and congressional district where the applicant is physically headquartered, not where the applicant is incorporated, e.g., CA – 4)

6. Service Area

Does the applicant intend to serve only unserved rural premises in any of the eligible Satellite Regions?

Yes No

Does the applicant intend to not serve premises within the existing service area of current RUS borrowers currently in build-out, or the service areas of Last Mile Awardees under the First Round NOFA, Second Round NOFA or the BTOP NOFA?

Yes No

7. Project Costs

Provide the total amount of the project proposal and the amount which the applicant is requesting in assistance:

Total amount of the proposal: $_____________

The amount in which the applicant is requesting in assistance: $_____________

Attachments

The remaining items, #8 - #21, are items/questions that the applicant will complete and attach in the same order outlined within the Application Guide. Additional attachment requirements will be explained further within the Application Guide.

Verify that the items below have been included within your application:

• 8. Executive summary

• 9. Applicant’s Ability to Provide Service

• 10. Service Offerings

• 11. Management Team Resumes

• 12. Organizational Readiness

• 13. Organizational Chart

• 14. Historical Financial Statements

• 15. Broadband Subscriber Estimates

• 16. Pro Forma 5-Year Financial Forecast and

• 17. Commitment of Capital Funding Support

• 18. Outstanding Obligations

• 19. Service Metrics

• 20. Project Build-Out Timeline and Key Milestones

• 21. Certifications

• Equal Opportunity and Nondiscrimination Certification

• Certification Regarding Debarment, Suspension, and Other Responsibility Matters –Primary Covered Transactions

• Certification Regarding Lobbying for Contracts, Grants, Loans, and Cooperative Agreements

Applicant Certification
The undersigned certifies that he or she is authorized to submit the application on behalf of the eligible entity(ies) listed on the application; that the Applicant has examined the application, that all of the information in the application, including certifications and forms submitted, all of which are part of the application, are material representations of fact and true and correct to the best of his or her knowledge; that the entity(ies) that is requesting funding pursuant to the application and any subawardees will comply with the terms, conditions, purposes, and federal requirements of the program; that no kickbacks were paid to anyone; and that a false, fictitious, or fradulent statement or claim on this application is grounds for denial or termination of an award, and/or possible punishment by a fine or imprisonment as provided in 18 U.S.C. § 1001 and civil violations of the False Claims Act (31 U.S.C. § 3729 et seq.). The undersigned also certifies that the entity(ies) he or she represents have and will comply with all applicable Federal, state, and local laws, rules, regulations, ordinances, codes, orders, and programmatic rules and requirements relating to the project. The Applicant acknowledges that failure to do so may result in rejection or deobligation of the award. The Applicant acknowledges that failure to comply with all federal and program rules could result in civil or criminal prosecution by the appropriate law enforcement authorities.
SIGNATURE OF AUTHORIZED OFFICIAL	TITLE	DATE

6