Appendix B


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