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Block 7: Certifications and Signatures

59 Signature

60 Date

61 Printed Name of Authorized Person

62 Title/Position of Authorized Person

63 Phone

Ext.

64 Email

65 Employer

66 Employer’s FCC RN

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act, 47

U.S.C. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 3 of the Commission’s Rules authorize the FCC to request the information on this form. The purpose of the information

is to determine your eligibility for certification as a health care provider. The information will be used by the Universal Service

Administrative Company and/or the staff of the Federal Communications Commission, to evaluate this form, to provide

information for enforcement and rulemaking proceedings and to maintain a current inventory of applicants, health care providers,

billed entities, and service providers. No authorization can be granted unless all information requested is provided. Failure to

provide all requested information will delay the processing of the application or result in the application being returned without

action. Information requested by this form will be available for public inspection. Your response is required to obtain the

requested authorization.

The public reporting for this collection of information is estimated to average 1 hour per response, including the time for

reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and

reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection

and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-PERM, Paperwork

Reduction Act Project (3060-0804), Washington, DC 20554. We will also accept your comments regarding the Paperwork

Reduction Act aspects of this collection via the Internet if you send them to pra@fcc.gov. PLEASE DO NOT

SEND YOUR RESPONSE TO THIS ADDRESS.

Remember - You are not required to respond to a collection of information sponsored by the Federal government, and the

government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to

provide you with this notice. This collection has been assigned an OMB control number of 3060-0804.

THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5

U.S.C. 552a(e)(3) AND THE PAPEWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C.

SECTION 3507.

FCC Form 460

Fcc Form 460 - Rural Health Care (Rhc) Universal Service - Eligibility And Registration Form Page 3