APPLICATION FOR CITY OF OMAHA CABLE

TELEVISION INTERCONNECT FEE AWARDS

Designate which of the following categories describes you or your organization:

_____ A resident of an area served by a cable television system holding a franchise with the City of Omaha.

_____ A governmental entity, religious organization, or accredited educational institution.

_____ A non-profit organization meeting Access Policies adopted by Cox Communications or the City of Omaha.

INDIVIDUAL APPLICATION Applicant's name, address and telephone number:	ORGANIZATION APPLICATION Name, address, and telephone number of organization and a contact person for legal notice & correspondence:
Name of the cable television operator serving your residence's area:

INDIVIDUALS Provide a brief history of your experience relating to cable television and any noteworthy cable-related projects in which you've participated.

ORGANIZATIONS Provide a brief history of the organization, including whether the organization is an association partnership, or non-profit corporation; identify all persons on the governing board; provide your mission statement; describe all program activities and goals; and describe any noteworthy cable-related projects in which the organization participated.

Attach additional pages if necessary to provide the requested information.

All information submitted on this application must be kept current during the use of any grant funds.

PROJECT DESCRIPTION

Provide a detailed description of the project, purchase, or other activity for which the grant funds will be used.

PROJECT BUDGET

Provide a detailed budget for the project, purchase, or activity showing all revenue, regardless of the source, and all projected expenses. Include a line item summary for all uses of the grant funds. A separate budget must be provided for each project, purchase, or activity included in your application. (Attach a separate page is necessary).

AMOUNT BEING SOUGHT FROM THE INTERCONNECT FEE FUND

If application includes more than one project, purchase, or activity, list the amounts separately.

OTHER FINANCIAL SUPPORT

List all sources of financial support for any cable-related activity in which you engage, including the amount of support provided during the past 12 months. Indicate what, if any, portion of this support will be used for the project, purchase, or activity which is the subject of this application.

PARTICIPATING ORGANIZATIONS OR PERSONS

List all organizations or persons participating in the proposed project or purchase.

ORGANIZATION MEMBERS

List all city employees or officials, employees or officers of any franchised cable operator, or members of the Cable Television Advisory Committee who are participating or are members of any participating organization and show any offices they hold in your organization..

READ BEFORE SIGNING

I certify that this application contains no willful misrepresentation and that the information is true and complete to the best of my knowledge. I understand that should investigation disclose any misrepresentation, my application will be rejected and I or my organization will be disqualified from applying for any grants under the jurisdiction of the Cable Television Advisory Committee of the City of Omaha, Nebraska.

Signed ____________________________________________________ Date ___________________________

Printed Name: __________________________________________________

Title: _________________________________________________________

Address: ___________________________________________ Telephone no.__________________