New Customer Registration Form

Applicant Details:

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Are you currently residing on Spokane Tribal Land?

Date of Birth

Date

Household size

Total Annual Household Income:

Eligibility (check one or more)

Proof of eligibility:

Can be pay stub or tax return

Proof of eligibility attached?

Current internet provider:

Account number (if applicable):

Monthly Internet Cost:

Requested Subsidy:

I certify that the information provided is true and correct.
I understand that this subsidy must be recertified annually to remain active. I understand I must submit my internet bills monthly, and if 30 days or more pass without submitting paperwork, Sp'q'n'i? Broadband Services reserves the right to offer the subsidy to the next qualified applicant. I agree to notify the Tribe of any changes in income, household size, or eligibility status. I also acknowledge that if eligibility status is not met, Spqni reserves the right to require repayment of the funds provided.

Signature

Tribal Resources for Universal Service & Technology (T.R.U.S.T) Application