Affordable Connectivity Program Enrollment Form

Affordable Connectivity Program Enrollment Form

The Affordable Connectivity Program (ACP) is a government-led initiative that offers low cost to no cost subsidies to gain home internet services for qualifying low income households
Personal Information
Name*

First NameLast Name
Email*
example@example.com
State of Residence*
Zipcode*
Demographic Information
Please select your age range*

16 - 2526 - 3536 - 4950+
Please select your cultural ethnicity*

White/CaucasionBlack/African AmericanLatin or SpanishTwo or More RacesOther
Gender*

MaleFemaleNon-BinaryTransOther
Pre-Eligibility Criteria
What best represents your current household income?

$0 - $25,000$25,001 - $40,000$40,0001 - $65,000$65001 - $80,000$80,000+
How many people live in your household (including yourself)?

1234+
Select the program(s) that you currently are a participant

Special Supplemental Nutritional Program for Woman & Infants (WIC)Supplemental Nutrition Assistance Program (SNAP)MedicaidSection 8Federal Pell GrantTribal Specific Program (Only choose if you live on tribal land)Supplemental Security Income (SSI)Not Applicable
Privacy Policy: The personal information submitted in this form is collected and processed for the sole purpose of triaging and completing enrollment registrations for the Affordable Connectity Program. The sharing of personal information with third parties is strictly enforced for the scope of this purpose only. This form is enrypted to ensure personal data protection and regulatory compliance with consumer data rights. Completion of the survey is not an opt-in to open solicitation beyond the purpose defined.
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Affordable Connectivity Program Enrollment Form

Personal Information

Demographic Information

Pre-Eligibility Criteria