THESE PAGES ARE HISTORICAL ONLY: OHIOLINK NOW REPORTS DIRECTLY TO THE CHANCELLOR OF THE OHIO DEPARTMENT OF HIGHER EDUCATION.
| Associated Institution (full address of main site) | Other sites of the institution to be included (name, city) | |
| ____________________________________ | _________________________________________ | |
| ____________________________________ | _________________________________________ | |
| ____________________________________ | _________________________________________ | |
| ____________________________________ | _________________________________________ | |
| ____________________________________ | _________________________________________ |
| Category (check one) | Bed Size | Population |
| Teaching Hospital | __NA__ | ______ |
| Non-Teaching Hospital | ______ | ______ |
| Clinic | ______ | ______ |
Effective Date Requested __________
| Requested Authorized Access Level (check one) | |||||||
|---|---|---|---|---|---|---|---|
| (Select proper column, enter quantity) | |||||||
| New | Add | Reduce | Price (From Appendix A) |
Annual Total |
Pro-Rated Percent |
Due Now |
|
| ____ | ____ | ____ | First simultaneous user | x ______ | = ______ | x ______ | = ______ |
| ____ | ____ | ____ | Added users | x ______ | = ______ | x ______ | = ______ |
Population ________ x $1.25 = _____________
Grand Total $ _____________
| Submitted by: | |
| ____________________ Name |
___________________________________ OhioLINK Medical Institution |
| ____________________ Title |
___________________________________ Date Submitted |
