Broadband Inquiry Form

Thank you for joining the Community and Economic Development Connect NNE demand aggregation project.
Your inquiry will be added to data from others to help define the network needs of your area.

All fields with an asterisk (*) MUST be completed

*First Name

*Last Name

Group or Affiliation name (if applicable)

*Service Address

*Service Address City

*Service Address State

*Service Address ZIP Code

Mailing Address (if different)

City (if different)

State (if different)

ZIP Code (if different)

If your service address is a Rural Route Address, P. O. Box, or other non-911-style address, please provide directions from the nearest major landmark.

*Service Phone Number

Contact Phone Number

Email Address

Do you already have Internet service at this location? If so, what kind of service do you have at present?

	I don't have any Internet service at this time.
	Dial-up
	DSL
	Cable Modem
	Fixed Wireless
	Satellite
	Other Internet

Is this service for your home, or for your business?

Home Business

Do you have any other special needs, or are there other Internet-related services in which you are interested?

	I am interested in Web site hosting.
	I am interested in eCommerce (selling my goods or services online).
	I use my connection to send or receive large files (large graphics, blueprints, professional audio or video)
	I am interested in VOIP (Voice-Over-IP, using my Internet connection to supplement or replace traditional phone service)
	I am interested in server co-location or dedicated hosting.

Are there any other special services you may need, or any other details relevant to your request? If so, please enter them here.