Remote Village Internet Survey & Request Form
Contact & Location Information
Full Name
Phone Number
Village Name
District/Area
Province/State
Approximate Population
Current Connectivity & Needs
Does your village have any access to the internet?
Yes
No
If yes, describe the type of connection
How many households need internet access?
What is the main purpose for requesting internet service? (Check all that apply)
Education
Healthcare
Business
Communication
Other
If other, please specify
Additional Comments or Needs