Fcc Form 486 - Schools And Libraries Universal Service Receipt Of Service Confirmation And Children'S Internet Protection Act And Technology Plan Certification Form Page 6
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Do Not Write In This Area
FCC Form 486
DO NOT STAPLE
Approval by OMB 3060-0853
Entity Number __________________ Applicant’s Form Identifier _______________________________________
Contact Person __________________________________ Phone Number _________________________________
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.
12. Signature of authorized person
13. Date
______________________________________________________________
14. Printed name of authorized person
15. Title or position of authorized person
16a. Street Address, P.O. Box, or Route Number
City
State
Zip Code
16b. Telephone number of authorized person
Extension
16c. Fax number of authorized person
16d. Email address of authorized person
16e. Name of authorized person’s employer
Page 6 of 7
FCC Form 486
December 2013
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