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2. Please provide your full home address. (Follow the examples exactly. No PO Box numbers. This is only used to identify demand for broadband services.)
4. Street Address (example: 1 Main St.)*
6. City ( Example: Frostburg)*
7. Zip Code: (5 digits only, example 21502)*
9. Is this location

   1. Single Family Home - owned by you
   2. Single Family Home - Rental
   3. Multi-Family Home - owned by you
   4. Multi-Family Rental
11. Do you have internet access at home?

    1. Yes
    2. Yes, but would like more speed options
    3. No
13. How important is Internet access to you or your household?

    1. Very important
    2. Somewhat important
    3. Not important
15. What is the speed of your internet connection?

    1. Dial-up only
    2. Less than 10 Mbps download
    3. Between 10 Mbps and 25 Mbps download
    4. Great than 25 Mbps download
    5. I don't know
17. Does or did high speed, affordable internet access influence where you chose to live?

    1. Yes

    1. No
19. For your household, how much do you spend each month for local and long distance telephone , TV, and/or Internet? Do NOT include cell phones unless that is your primary source for internet in the home.

    1. $50 or less
    2. $50 to $75
    3. $75 to $100
    4. $100 to $150
    5. 150 to $200
    6. More than $200/month
21. How much do you pay now for at home Internet access each month?

    1. No Internet
    2. I only use free hotspots
    3. Under $25
    4. Under $50
    5. Under $75
    6. More than $75 / month
    7. I don't know
    8. My internet is part of a package
23. What would you be willing to pay for a faster, higher quality Internet connection?

    1. $10 to $20
    2. $21 to $40
    3. $41 to $60
    4. $61 to $80
    5. More than $80/month
    6. Not willing to pay more
25. What type of Internet do you have at home?

    1. Dial-Up
    2. Cable Modem (Comcast, Atlantic Broadband)
    3. DSL Line
    4. Fiber
    5. Satellite (Hughes, Dish, Directv)
    6. Cellular Wireless
    7. Broadband WISP (TWR, Skypacket)
27. Based on the type of Internet connection you selected above, why do you still have it? (select all that apply)

    1. Meets my needs for price and speed
    2. Best price available
    3. Most reliable service available
    4. Too expensive to change
    5. No other options
29. What is your age?
    -- Select One --Under 1818-2425-3435-4445-5455-6465-74
31. Total number of adults in household:
33. Total number of internet users in household:
35. Are there any children of school age K-12 living at this address?

    1. Yes
    2. No
37. Is anyone in your household taking college or job training courses online?

    1. Yes
    2. No
39. How many devices (for example computers, cellphones, smart TVs) connect to the Internet in you household?

    1. 0-1
    2. 2-4
    3. 5-6

    1. 7-8
    2. 9-10
    3. 10+
41. What do you most often use the Internet for? Check all that apply

    1. Browsing (looking at websites)
    2. Business (telework, or telecommute)
    3. Email
    4. Homework / Schoolwork
    5. Music Streaming (iHeart Radio, Pandora, Spotify)
    6. News
    7. Online Shopping
    8. Online Backup
    9. Maintain Website, blog
    10. Pay Bills, Personal banking
    11. Search for Work
    12. Social Media (for example: Facebook, Twitter, etc.)
    13. Telehealth (for example: doctor visit by Internet)
    14. Video & Phone Calls via the Internet
    15. Video Games
    16. Video Streaming (for example: Netflix, YouTube)
43. What would you like to be able to do online that you can't with your current connection? (Check all that apply)

    1. Nothing - current connection meets my needs
    2. Work from home (i.e. telework or telecommute)
    3. Online education and training
    4. Audio/video streaming
    5. Video/web conferencing
    6. Transmit large data files
    7. Healthcare communications/monitoring
    8. Financial/banking transactions
    9. Online shopping
    10. Other
45. Does anyone in your household use the Internet to work from home (i.e. telework or telecommute)?

    1. Yes
    2. No
    3. No, but I would if I had Internet access/better access at home
47. Select the items you agree with:

    1. I need better landline service
    2. I need better cellular telephone service coverage
    3. I need more cellular service options
    4. I need better internet service pricing
    5. I need more reliable internet service
    6. I need more internet service speed options
    7. I am satisifed with all my services
49. Does anyone in your home operate a home based business?

    1. Yes
    2. No
51. Do you own a business?

    1. Yes
    2. No
53. Who is your internet service provider?
55. Who is your cable/satellite tv provider?
57. Who is your telephone service provider?
59. Please add any other information about your internet needs at this location:
61. Name
62. Email Address
64. Address
66. City
67. State
68. Zip Code
70. Phone Number
71. Fax Number
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

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