Do you qualify for a FREE tablet & internet?
Please complete the form below to apply for the Affordable Connectivity Program (ACP). If qualified, you will recieve a free tablet and free internet through the duration of the Affordable Connectivity Program (ACP) and while you have benefits. Please note, there is a one-time $20 (non-refundable) avtivation fee, if approved.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Phone Number
*
Email Address
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Last 4 digits of your SSN:
*
How did you hear about us?
*
Current internet provider?
*
Which program are you applying for?
*
Please Select
Affordable Connectivity Program (ACP)
Which eligibility program are you qualifying through?
*
Please Select
Free or Reduced Lunch
Lifeline Assistance Program
Medicaid
Section 8, Public Housing Assistance
Supplemental Nutrition Assistance Program (SNAP)
Supplemental Security Income (SSI)
Veterans & Survivors Pension Benefits
Women, Infants, & Children (WIC)
Proof of program eligibility may be requested at a later date.
Are you qualifying through a child?
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Yes
No
Child's Name
*
First Name
Last Name
Child's date of birth
*
-
Month
-
Day
Year
Date
Last 4 digits of child's SSN:
*
Proof of qualifying benefits/Verification letter (only)
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Optional, however, you may be asked to provide this at a later date.
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of
Driver's License or State ID (front)
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Please verify that you are human
*
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