Somerset 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
*
E-mail
example@example.com
Have you declined broadband installation to your home due to excessive cost?
Yes
No
Is your house part of a shared driveway where others might 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: