3504-2942 BEAD-Funded Connect Illinois Round 4

The application form is the final form for an application to Connect Illinois Round 4 (the BEAD Program) to be considered complete. Failure to submit this form will prevent your application from being considered for Connect Illinois Round 4.

Before proceeding, you must have completed Part 1: Entity Form and Part 2: Project Form to submit the Application Form.

Questions? Contact broadband@illinios.gov.

Click here for more information and guidance on the BEAD application process.

By checking this box I understand for my application to be considered, my entity must be GATA pre-qualified prior to application deadline. For more information on GATA pre-qualification, please visit https://www2.illinois.gov/dceo/AboutDCEO/GrantOpportunities/Pages/GranteeResources.aspx.*

Contact First Name*

Contact Last Name*

Contact Email Address*

Contact Phone Number*

Phone

Applicant Legal Name*

Enter the legal entity name which matches what was provided in the Entity Submission Form, E.AD.1.

Doing Business As (DBA)*

Enter the DBA which matches what was provided in the Entity Submission Form, E.AD.2.

Employer/Taxpayer Identification Number (EIN/TIN)*

Project Name*

Enter the project name identified in Project Submission Form, P.AD.1.

Entity Form Submission ID*

Enter the EFS ID provided to the primary and secondary contacts upon submission of the Entity Submission Form.

Project Form Submission ID*

Enter the PFS ID provided to the primary and secondary contacts upon submission of the Project Submission Form.

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