FREE INTERNET W/TABLET APPLICATION
Name As It Appears On Your Benefit Document.
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date Of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Last 4 Digits of Social
Name of Qualifying Child
First Name
Last Name
Additional Notes If Needed
Have you received a free government phone in the past 12 months?
Please Select
Yes
No
Have you received a free government tablet in the past 12 months?
Please Select
Yes
No
Which government benefit do you receive?
Please Select
SNAP/Food Stamps
WIC
Federal Pell Grant*
Medicaid
Social Security Income
Federal Public Housing Assistance
My child gets Free/Reduced School Breakfast/Lunch
Veterans & Survivors Pension Benefit
Household Income
Tribal Indian ID
If approved are you able to provide proof of your benefit?
Please Select
Yes
No
If approved are you able to pay $20 setup fee?
Please Select
Yes
No
Upload Drivers License or ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Proof of Benefit
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: