Appendix B

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

 

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