• Affordable Connectivity Program (ACP)

    Customer Opt-In Form

  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  • Please read and initial each of the following to participate in the ACP Program.

  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  •  -  -
    Pick a Date
  • IF you are transfering your ACP benefit to RTC Communications please read and initial each of the following.

  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • FOR INTERNAL USE ONLY

  •  -  -
    Pick a Date
  • NOTE: THIS RECORD AND ANY RELATED DOCUMENTATION OF ELIGIBILITY MUST BE MAINTAINED FOR A MINIMUM OF 6 YEARS AFTER THE LAST DATE THE ABOVE-NAMED CUSTOMER RECEIVED ACP BENEFITS.

  •  
  • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free! Create your own Jotform