Customer Opt-In Form

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    Select one.
  • Benefit Qualifying Person (Child/Dependent) Information

    If your eligibility for the Affordable Connectivity Program through the National Verifier was based on a Benefit Qualifying Person (Child/Person), we will need the following information for the individual used for eligibility in the program. Ex. Student's Info based on Free & Reduced Lunch Program
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  • Acknowledgments

    Below you will find ACP requirements, rules and/or restrictions. Read and acknowledge all applicable statements below. Failure to fully accept all program statements may result in disqualification from ACP participation.
    Failure to fully accept all statements may result in ACP program disqualification.
  • Signature

  • Please type your name.
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