Application form educational service cooperative



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Arkansas Public School Computer Network

FY 2004

STATEWIDE INFORMATION SYSTEM (SIS) COORDINATORS

APPLICATION FORM

EDUCATIONAL SERVICE COOPERATIVE:
Coop Name:_____________________________________

DISTRICT:
Name: __________________________________________

Address: __________________________________________

City/Zip Code: __________________________________________

Phone Number: ________________ Fax Number:_______________


SIS COORDINATOR:
Full Name: _______________________________________________

Login Name: _______________________________________________

(Login should be the same as it is accessing Pentamation software)

Phone Number: _______________________________________________


CYCLE 1 COORDINATOR (if different than above):

Full Name: _______________________________________________

Login Name: _______________________________________________

(Login should be the same as it is accessing Pentamation software)

Phone Number: _______________________________________________
SUPERINTENDENT - SIGNATURE AND DATE:
__________________________________________ _______________

Superintendent=s Signature Date


Revised: 08/20/96 Fax completed form to Tinika Ricks, 501-682-5035




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