First Name
Last Name
Business email *
Phone *
Number Are you interested in a free, no obligation quote for your organization’s broadband connectivity services? * Yes No
Your Organization Name *
Organization Type -Select- Non-Profit Hospital Community Health Center Health Department or Agency Community Mental Health Center Rural Health Clinic Dedicated Emergency Room of Rural FOR Profit Hospital Skilled Nursing Facility Educational institution for healthcare instruction, (i.e., teaching hospitals or medical school) OTHER
Please select the type of organization that most closely resembles your organization from the list below. * -Select- Non-Profit Public For Profit Unsure
Organization Address (Street, City, NC & Zip Code)
Street Address
Address Line 2
City
State/Region/Province
Postal / Zip Code If you'd like to check multiple sites eligibility, please include the additional addresses in an excel sheet or other compatible document and upload it here.
Would you like to receive email communication focused on broadband and connectivity access in the NC Healthcare Community from NCTNA? * Yes! No
