Line Extension Customer Assistance Program - Internet Service Provider Referral Form

Submit Application

Application Submission Steps:

All fields marked With * Are required for submissions. Click Please Note: Fields marked with + are required if address information is is not the same as applicant's

Please Note: Most questions can be answered with Yes Or No. Some questions may require you to enter in longer form answers

When form is complete please submit it to DHCD by clicking the Submit Button.

If you have an questions please contact: DHCD LECAP Program.

I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this Application void and will be cause for termination, whenever discovered.***

Fields Marked With * Are Required For Application Submission
Applicant Information:

The information below should be completed with information from proposed LECAP benefactor:

Property Questions and Information

*Physical Virginia Address: This is the location that LECAP assistance would assist in connecting

Applicat Information

Please answer the questions below with Yes or No

*The ISP which I represent has an existing broadband network in proximity to the referred property, as defined in LECAP Guidelines and Criteria.

Yes | No

______________

*The ISP which I represent has responded to and been qualified under the process established in the Request for Information offered by the Department of Housing and Community Development

Yes | No

Certification Statement:

*I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this Application void and will be cause for termination, whenever discovered.***

Yes | No