Rural Health Care

Required Forms

The forms may be revised each funding year. Applicants must use the correct funding year form to participate.

Applicants are encouraged, if possible, to e-cert and submit their forms electronically.

 

 

Applicant Forms - Fund Year 2011

FY 2011 Form 465
Description of Services Requested & Certification Form

Apply Online  or

Download only:   Download FY 2010 Form 465 (Excel)135kb  |   Download FY 2010 Form 465 (PDF)  251kb

View instructions  

Download:   View FY 2010 Form 465 instructions (PDF) 66kb

FY 2011 Form 466
Funding Request & Certification Form

Apply Online  or

Download only:   Download FY 2010 Form 465 (Excel) 268kb  |   Download FY 2010 Form 466 (PDF)  353kb

View instructions  

Download:   View FY 2010 Form 466 instructions (PDF) 64kb

FY 2011 Form 466-A
Internet Service Funding Request & Certification Form

Apply Online  or

Download only:   Download FY 2010 Form 465 (Excel) 125kb  |   Download FY 2010 Form 466-A (PDF) 261kb

View instructions  

Download:   View FY 2010 Form 466-A instructions (PDF) 37kb

FY 2011 Form 467
Connection Certification Form

Apply Online  or

Download only:   Download FY 2010 Form 465 (Excel) 125kb  |   Download FY 2010 Form 467 (PDF) 242kb

View instructions  

Download:    View FY 2010 Form 467 instructions (PDF) 33kb

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Service Provider Forms

 

Form 498
Service Provider Identification Number and Contact Information Form

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Last modified on 4/1/2011