Telecommunications Complaint-Inquiry (CI) Form

Edit Form

Name:*

Address:*

City:*

State:*

Zip:*

Telephone:*

Email Address:*

District: --Select One-- Aquia Falmouth Garrisonville George Washington Griffis Widewater Hartwood Rock Hill

I acknowledge that all broadband issues (cable and internet) are the responsibility of the provider. All complaints will be sent to the respective cable provider representative.*

Yes

No

ssue:*

Cable

Internet

No Service

Provider:*

Verizon

Cavalier

Comcast

Cox

Other

Estimated Homes-per-linear-mile (HPLM)

Dwelling Distance from Main Drop (road)

Description of problem:*

Release authorization opt-in (recommended): I/We authorize the county to release my/our contact information to the Franchise Providers (Comcast, Verizon or Cox) or any other vendors that may request it so that the County can best address my complaint-inquiry and so that I/We may learn of other services or products that may meet my/our stated Telecommunications needs*

Yes

No