
Do you currently have Internet service at your home?
Yes
No
Which Provider?: Provider Name:

Would you like to have a faster and more reliable Internet service?
Yes
No
Explain:

Number of people living in household:
1
2
3
4
5 or more

Does anyone in the household have health needs that high-speed Broadband would help?
(Connecting online with doctor's office or the V.A., telemedicine, online prescription refills, medical monitoring, etc.)
Yes
No
Explain:

Is anyone living in the household disabled?
Yes
No
Explain:

Are there students in the household that need reliable, high-speed Broadband for schoolwork?
Yes
No
Explain:

Does anyone in the household need reliable, high-speed Broadband to work from home?
Yes
No
Explain:

Do you run a business from home?
Yes
No
Explain:

Do you participate in farming activities (crops, livestock, etc.)?
Yes
No
Explain:

Name
First	Last

Address
Street Address

Address Line 2

City	State

ZIP Code

Phone	Email


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