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2. Connect My Home
4. Please note: This application process requires documents to be uploaded for completion. It is suggested that all documents be ready before beginning the application process.
6. Applicant Information
8. Project Name:*
10. Physical Address:*
12. City:*
13. State:*
14. Zip Code:*
16. Contact Information
18. Primary Contact Name:*
20. Primary Contact Telephone Number:*
22. Primary Contact Email Address:*
24. Broadband Service Provider:*
26. Service Provider Point of Contact Name:*
28. Service Provider Point of Contact Telephone Number:*
30. Service Provider Point of Contact Email Address:*
32. Project Information:
34. Project Total Cost:*
36. Estimated Funding Sources:
38. Applicant:*
40. Allegany County Contribution:*
42. Other:*
44. Project is designed to meet high speed technical standards*

    1. Yes, designed to meet or exceed symmetrical 100 Mbps download and upload speeds.
    2. Exception requested, designed to reliably meet or exceed 100/20 Mbps
46. The Broadband Service Provider participates in a low-income subsidy program*

    1. Provide access to a broad-based affordability program to low-income consumers that provides benefits commensurate to ACP
    2. Participates in FCC's Affordable Connectivity Program (ACP)

    Broadband service providers are required to include at least one low-cost option offered without data usage caps at speeds sufficient for a household with multiple users to simultaneously telework and engage in remote learning.

48. Proposed Funding Area (PFSA) Description:*
50. Area for Investment*

    1. Lack of access to a reliable high-speed broadband connection
    2. Lack of affordable broadband
    3. Lack of reliable service

    Check all conditions that apply.

52. Upload Map of PFSA:*

    Map showing properties to receive service in the proposed service area including finite boundaries for each area must be attached to the application. 

54. Technology Used to Serve the Subscriber:*

    1. Fiber Optics to Premise
    2. Unlicensed Fixed Wireless
    3. Licensed Fixed Wireless
    4. Other
56. If Wireless, Frequency Band:
58. If Other, please provided description:
60. Number of Unserved Households and Businesses passed:

    This is your projected subscriber base 

62. Households:*
64. Businesses:*
66. Other:*
68. Average Number of homes and businesses per mile (wired): *
70. Average Number of homes and businesses per tower (wireless):*
72. Contractor & Vendor Estimates & Quotes*
74. I am in good standing with Allegany County Government and the State of Maryland with NO outstanding taxes, fees, or other charges?*

    1. Yes
    2. No
    3. Inapplicable, because I am starting a new business venture.

    To verify “good standing” status in Maryland, click here. To ensure active and good standing status, click here.

76. If I receive a a grant, please mail the check to:
78. Contact Name:*
80. Mailing Address:*
82. City:*
83. State:*
84. Zip Code:*
86. To the best of my knowledge and belief, the information contained in this application package is true and correct and I have the authority to sign this document. By completing this application, the applicant accepts the above terms, project details, and meets the eligibility requirements:
88. I have reviewed and accepted the terms above*

    1. Yes
90. Applicant Name*
91. Date:*
93. Title:
Leave This Blank:


97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit Submit and Print

* indicates a required field