AFFORDABLEDEVICES APPLICATION FORM

Affordable Devices

Application Form
Do Not Enter False Information That Will Only Deny Your Application
Qualifying Program*
What benefits do you recieve?
Courtesy Title*
Please choose which Prefix
Name*

First NameLast Name
Social Security#*
Last 4 Digits
Birthdate*

MonthDayYear
Telephone Number*
Email Address*
example@example.com
Address*

Street Address

Apt/Unit #

CityState

Zip Code
Pick Your Device*
What Device are you Applying for?
How did you hear about us?*
THIS SECTION IS FOR:

SSI BENEFITS OR W-2 LOW INCOME-BASED

CUSTOMERS ONLY

PLEASE: Use a BLACK BACKGROUND & Make sure ALL FOUR CORNERS ARE VISABLE
SSI Benefits Award Letter/ Low-Income W-2

Please upload a copy of your award letter for SSI or Low-Income W-2
Cancelof
Should be Empty:

Affordable Devices