Broadband Request Form – Palmetto Care Connections

PCC Funding Request Form

Please complete the PCC Funding Request form downloadable here and email to Information Technology Director Matt Hiatt at matth@palmettocareconnections.org. You can also fill out the online form below.

Broadband Request Form

Site Name*
Legal Entity Name*
Site Address*
Street Address Address Line 2 City State ZIP Code
Is mailing address same as site address?*
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Date
Date Format: MM slash DD slash YYYY
Author's Title*
Site Contact*
First Last
Site Contact Phone*
Site Contact Email Address*
Enter Email Confirm Email
Service Location Address
Street Address Address Line 2 City State ZIP Code
Tax ID
NPI
Taxonomy
Select One:*
- For Profit
- Non-Profit
Type of Organization
In Building Termination Location
IT Tech Contact
First Last
IT Tech Phone
IT Tech Email
Bandwidth Needed
Equipment Needed
(i.e. firewall, router, core switch, etc....)
Technologies desired to use over connection: