In accordance with sections 191.10 to 191.45 of the Revised Code, a provider may submit an application for a program reimbursement under the Ohio broadband pole replacement and undergrounding program, if the provider has deployed qualifying broadband infrastructure in an unserved area and has paid any of the following costs in connection with the deployment of such broadband infrastructure:

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(A) Pole replacement costs;

(B) Mid-span pole installation costs;

(C) Undergrounding costs.

The application shall be submitted on a form prescribed by the department of development.