Attachment Request Form

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Request for Attachment to
Dominion Electric Distribution Poles

Use this form to initiate the request process for attaching a telecommunication device on an electric distribution pole. As an alternative, use our printer-friendly form (MS-Word doc) that you can return by e-mail at your convenience. Contact us if you need any assistance.

Name:
Title:
Company:
Street Address:
City:
State:
Zip Code:
E-mail Address:
Business Phone:
Alternate Phone:
Fax Number:
Type of Business: (Telecommunications, Cable TV, Other (LLP, LLC, etc.), Municipality, Government Agency)
County or Municipality where attachments will be located:
Date that attachments are needed:
Is this a permanent or temporary attachment (less than 90 days):
Pole Information: (Street location, type of pole, such as wood, concrete, etc., other identifying information on the pole such as birthmark, tags, numbers, etc.)
Description of attachment: (Click here for examples of useful information)