RM_StatsFirst name *Last name *Phone Number *Email Address *Dwelling Type *Select an optionPublic HousingApartmentDuplexSingle HouseStreet Address *Unit #City / Town *Province / State *Postal Code / Zipcode *Infrastructure Choices Infrastructure 1 Infrastructure 2 Infrastructure 3 Select Eligibility Option *Select an optionLow Income (Urban)Low Income (Rural)Proof of household income *e-Signature * I authorize necessary confirmation with government entity regarding reported household income Service is not currently available in your area Please contact me when available in my area Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.