Application Form
First Name
*
Last Name
*
Title
*
Mr.
Ms.
Department
*
Employer
*
Address
*
Address 2
*
City
*
State / Province
*
Zip/Postal Code
*
Country
*
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, The Democratic Republic of The
Cook Islands
Costa Rica
Cote D'ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-bissau
Guyana
Haiti
Heard and Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic Of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and The Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and The South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
West Bank/Gaza
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Area Code
*
Phone
*
Fax
*
Email
*
Website URL
*
School District
*
Education Level:
*
Grades 7-9 (Junior High/Middle School)
Grades 9-12 (High School)
2 Year College (Community College)
4+ Year Colleges/University/Grad Schools
Vocational Ed
Technical School or Polytechnic Institute
Education Cooperative/Service Centers
Non-Profit Organization
Other
If Other:
*
School Type:
Non-Profit
For-Profit
School Accreditation:
Accredited
Not Accredited
Are you interested in being a:
Local Academy
*
Regional Academy
Both Local and Regional
Current Enrollment:
(Total number of students
at your school / institution)
Less than 500
500-1,000
1,001-3,000
3,001-10,000
Greater than 10,000
Number of instructors:
(Total number of full or part-time
instructors at your school / institution)
Less than 50
50-100
101-500
501-1,000
Greater than 1,000
Technology Coordinators:
(Total number at your school / institution)
None
1-5
6-10
11-20
Greater than 20
Instructional Computers:
(Total number at your school / institution)
Less than 50
51-100
101-500
501-1,000
Greater than 1,000
Does your school / institution
currently use a
computer network?
Yes
No
When does your school / institution plan on
purchasing computer networking equipment
?
3 months
6 months
1 year
2 or more years
Are you the
person responsible
for determining which new curriculum your school/institution will adopt?
Yes
No
If not, please provide the following
information
for this person:
Name:
Telephone Number:
Email Address:
Are you the
person responsible
for purchasing network technology for your school / institution?
Yes
No
If not, please provide the following
information
for this person:
Name:
Telephone Number:
Email Address:
Dedicated Internet Connection:
(Does your school / institution have a dedicated, non-dial-up Internet connection of at least 56KB?)
*
Yes
No
If
YES
, what is the current connection speed?
None
Analog Modem 56k
ISDN - 64k to 128K
DSL or Cable Modem - 128k to 1.5mps
Other Broadband - Greater than 128k
T1 - 1.5mps or greater
Greater than 1.5mps - more than a T1
If not, are you planning to
install
one in the next 6 months?
Yes
No
Classroom Computer Setup?
(At least 1 classroom set up with less-than-three-year-old PCs or Macs with a student-to-computer ratio less than 3:1?)
*
Yes
No
If not, are you planning to
purchase these
in the next 6 months?
Yes
No
Proper Classroom Space?
(At least 1500 square feet of non-dedicated classroom and lab space for Networking Academy classes?)
*
Yes
No
If not, are you willing to
allocate this space
within 6 months?
Yes
No
Primary Instructor?
(Do you have an instructor you would be willing to assign to teach Networking Academy classes?)
*
Yes
No
If not, are you willing to
assign
at least one such instructor in the next 6 months?
Yes
No
Backup Instructor?
(Do you have a backup instructor who can teach Networking Academy classes when the primary instructor is out?)
Yes
No
If not, are you willing to
assign
at least one such instructor in the next 6 months?
Yes
No
Institution Support?
(Do you currently have the support of those at your institution who have the authority to decide to offer the Networking Academy program?)
Yes
No
If not, are you confident you can
gain this support
within the next 6 months?
Yes
No
Start Date?
(When do you plan to begin offering the Academy curriculum?)
*
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2006
2007
2008
Language preference?
(for polling purposes only)
English
Spanish
French
Russian
Japanese
German
Other
Please name the three most prevalent brands of
networking equipment installed at your institution.
(Please note that successful operation of the Cisco Networking Academy program DOES NOT require that the network at your institution consist of Cisco networking equipment.):
Most prevalent brand:
Second-most prevalent brand:
Third-most prevalent brand:
Where did you hear about us?
T.V. Show/News program
Internet
Magazine article
Newspaper article
Radio program/ad
Friend/Co-worker
Trade Show/Meeting
Other
If "other," please specify:
*
Required Fields