Apply for PEI Broadband Fund Residential Pilot

First Name

Middle Initial

Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345

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Telephone Number

For example 902-555-5555

Email Address

Cell Phone Number

For example 902-555-5555

County - Select -PrinceQueensKings

Is the civic address/location of this project different from the address above? - Select -YesNo

Civic Address

Address

City, Town or Community

Postal Code

For example C1B 0X0 or 12345

Applying as: - Select -Property OwnerLeaseholder with Approval from the Property Owner

Are you a full-time permanent resident of PEI? - Select -YesNo