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Registration Form
Name
*
First Name
Last Name
Phone / Mobile
*
-
Area Code
Phone Number
E-mail Address
*
example@example.com
Service Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Date of birth
-
Month
-
Day
Year
Date
Address
APT LOT OR UNIT
Choose a service
*
5-100mbps: $0/mo
500mbps: $15-30/mo
1gig: $30-60/mo
Home Phone: $25/mo
Benefits you or your dependant qualify for:
*
EBT/Snap/Food Stamps
Medicaid
SSI Supplemental Supply Income
Veterans Pension
FPHA (Federal Public Housing Assistance)
WIC
Child or Dependent participates in Free or Reduced School Lunch
Received a Federal Pell Grant in the current award year
I qualify through my income
Household size
1
2
3
4
5
6
7
8
9
Who is your current internet provider?
*
I currently don´t have internet
AT&T
Kinetic
Frontier
Hughesnet
T-Mobile Home Internet
Spectrum
Viasat
Xfinity
Other
Language you prefer to be contacted
*
English
Spanish
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