Enrollment form
Please fill out the information below to see if you qualify for a device through the ACP Program.
Full Name (as listed on benefit documents)
*
First Name
Last Name
Address (where your benefits are registered)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Last four of Social Security (SSN)
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Please attach the documents for which you are qualifying with! (Food stamp/Medicaid card and letter or 2022 W2 etc)- This is REQUIRED for you to be approved!
*
Browse Files
Drag and drop files here
Choose a file
(Food Stamp or Medicaid letter of approval, Proof of SSI or Veterans Pension (etc), 2022 W2 for Low Income)
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Is there anyone (friends, family, coworkers) who you think would be interested in a device through the ACP Program? If so, please put their info down below!
Rows
Full Name
Contact Number
1
2
3
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