Application Form
First Name *
Last Name *
Title *
Department *
Employer *
Address *
Address 2 *
City *
State / Province *
Zip/Postal Code *
Country *
Area Code *
Phone *
Fax *
Email *
Website URL *
School District *
Education Level: *
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?
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 Year
Language preference?
(for polling purposes only)
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?
If "other," please specify:

*Required Fields