Appendix B

Associated Institution (full address of main site) Other sites of the institution to be included (name, city)
____________________________________ _________________________________________
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Category (check one)Bed SizePopulation
   
Teaching Hospital__NA________
Non-Teaching Hospital____________
Clinic____________

Effective Date Requested __________

Requested Authorized Access Level (check one)
(Select proper column, enter quantity)
NewAddReduce Price
(From Appendix A)
Annual
Total
Pro-Rated
Percent
Due
Now
____________First simultaneous userx ______= ______x ______= ______
____________Added usersx ______= ______x ______= ______

Population ________ x $1.25 = _____________

Grand Total $ _____________

Submitted by: 
____________________
Name
___________________________________
OhioLINK Medical Institution
____________________
Title
___________________________________
Date Submitted