5.b connection-application-household
1
Minnesota Broadband Line Extension Connection Household Application
Instructions:
1. Complete the form. Required* fields are in bold and designated with an asterisk (*).
2. Return the completed form to: Office of Broadband Development, 1st National Bank
Building, 332 Minnesota Street, Suite E200, St. Paul, MN 55101
Eligibility: A household can apply to the Line Extension Connection program if it does not
have wireline internet service of at least 25 Mbps download/3 Mbps upload.
For assistance completing the form, please call 651-259-7610 or email DEED.broadband@state.mn.us
Contact: *First Name __________________________________ *Last Name __________________________________
*Phone (________)_______________________________ Email Address______________________________________
Address for Portal: *Street Address _______________________________________ *Is this a multi-unit building? Yes No
*City __________________________ *Zip/Postal Code _________________ *County ________________________
Please provide information for your location that will help inform Minnesota’s planning for future broadband programs:
# of people living in household:________ # of K-12 students in household: ________ # of Teleworkers in household: ________
Broadband Internet Information: *Do you have a broadband subscription at your address? Yes No
If Yes, Name of current broadband provider:______________________ Current monthly subscription cost?______________
Speed Test Results: Download (Mbps): ________________ Upload (Mbps): _________________
Please use the site https://www.speedtest.net to obtain your current internet speed for download and upload.
If you DO NOT have a current broadband subscription, please describe the barriers preventing you from accessing internet from
any existing providers in your area and list any known area providers:
Anything else you would like to share about the need for broadband to your home?
Affidavit
I affirm that I am at least 18 years of age, and all the above statements are true to the best of my knowledge. I agree to allow the
State of Minnesota to validate information in this application as necessary to ensure eligibility. I understand that by submitting my
address into the Line Extension Portal, I agree to make my address available to Internet Service Providers (ISPs) so they may
compete in a reverse auction (low bidder), to win a grant to build broadband infrastructure (a line extension) to my address
location. Submitting my address is not a guarantee that an ISP will bid or be awarded a grant to build service to my location.
*Signature _______________________________________________ *Date____________________