I want...
A free phone
A tablet without internet $20
A tablet with 12 months of free internet $25
A free phone and tablet $20
Name
*
First Name
Last Name
Delivery Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
A phone number you can be reached at
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you go to college?
*
Yes
No
Do you receive any government benefits such as ssi, food stamps, student loans, pell grants, medicaid, section 8, subsidized housing, etc
*
Yes
No
Best way to get in contact with you?
Call
Text
Address
What is your tablet referral code?
To verify eligibility in this government program what is the last 4 digits of your social?
*
Submit
Should be Empty: