Free Phone Service Application
Bring Your Own Phone Program with Assurance Wireless
Customer Details:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number or alternative contact person
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Last four digits of your social
*
Which benefits do you have ?
*
SNAP Supplemental Nutrition Assistance Program
Medicaid
SSI Supplemental Security Income
Veterans Pension or Survivors Benefit Programs
Federal Public Housing Assistance (FPHA)
Tribal Specific Programs
2024 W2 or Income statement- you can qualify using your income
State ID or Drivers License (must show all four corners, clear, and not expired. If you dont have this please upload Alternative ID-A & Alternative ID-B
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Alternative ID- A Can be mail still in the envelope less than 90 days old or a benefit statement with your name & address. Please upload Alternative ID-B next
Browse Files
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Choose a file
Cancel
of
Alternative ID-B Can be your birth certificate or social security card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Proof of benefits
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Choose an account pin#
*
Phone Options
*
Please Select
Bring my own unlocked phone (not locked to another network)
Buy a device for $25
If youre Bringing your own device please enter your phones IMEI number
Signature
*
Continue
Continue
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