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Check here for information on how to complete this form. Domain Name Requested:____________________________________________ School Name:_____________________________________________________ School District Affiliation:_____________________________________________ School Type:__________________ Description of School:__________________ _______________________________________________________________ _______________________________________________________________ School Tech Name:________________________________________________ School Tech Title:_________________________________________________ School Tech Postal:________________________________________________ _______________________________________________________________ School Tech Phone:_________________ School Tech Fax:_________________ School Tech Mailbox:_______________________________________________ School Admin Name:_______________________________________________ School Admin Title:_________________________________________________ School Admin Postal:________________________________________________ ________________________________________________________________ School Admin Phone:________________ School Admin Fax:________________ School Admin Mailbox:______________________________________________ District IT Manager:_________________________________________________ District IT Manager Postal:____________________________________________ ________________________________________________________________ District IT Manager Phone:____________________________________________ District IT Manager Fax:______________________________________________ District IT Manager Mailbox:___________________________________________ Connection Type:___________________________________________________ Networked Computers:_______________ Networked Windows:______________
School Tech Signature:____________________________ Date:______________ School Admin Signature:___________________________ Date:______________ District IT Manager Signature:_______________________ Date:______________
Approved:______________ Authorization:__________________ Date:______________ Type: STELLAR Cable______ STELLAR SLIP______ STELLAR Null Modem _______ Other_________________________________________________________________ Network Address:_____________________ Broadcast Address:___________________ Domain Name:__________________________________________________________
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