Zap the Gap

Internet Service Survey

The purpose of this survey is to determine those areas of Mississippi which do not have broadband internet service. If you have broadband internet service, please do not complete this form. Please only complete one survey per household or business. Completing this form does not guarantee utility service additions will occur.

Contact Information

Prefix First Name * Last Name * Suffix

Physical Address 1 *

Physical Address 2

City * State Zip * County *
MS

This Location is Primarily a

Billing Address is same as physical address

Billing Address 1

Billing Address 2

City State Zip

Primary Phone * Secondary Phone

Email Address (Required to receive email confirmation)