Carroll County Difficult to Serve – Long Driveway Application
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Have you declined broadband installation to your home due to excessive cost? EX: You received an estimate to connect your house from Comcast or Quantum?
Yes
No
If yes, what was the estimate amount?
What was the date of the estimate?
-
Month
-
Day
Year
Date
Who was the service provider?
Is your house part of a shared driveway where others would want services too?
Yes
No
Do you agree to allow us to share your information with the service provider that would connect your home?
Yes
No
Submit
Should be Empty: