Internet Request - EBB

Internet Request- Affordable Connectivity Program

Fill in your information below to qualify for ACP-funded internet.

What kinds of goals do you have for yourself in the next 6-12 months?*

Do you currently have internet?/¿Actualmente tienes internet?*

Primary Language/Idioma*

Name/Nombre*

First Name

Last Name

Do you have a cell phone?/Tiene un telefono celular?*

Phone*

Email

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Government Assistance/Asistencia de Gobierno? Check all that apply *

SNAP/EBT Food Stamps (CalFresh) Medi-Cal (Medicaid) SSI (Supplemental Security Income) SSDI (Social Security Disability) NSLP (National School Lunch Program) Public Housing Assistance or Section 8 voucher Lifeline Other I am not sure

-SNAP, EBT food stamps, and CalFresh provide assistance in purchasing food for the home. -Medi-Cal is health insurance provided by California. -Supplemental Security Income is government program that provides stipends to low-income people who are aged 65 or older. -Social Security program that pays monthly benefits to you if you become disabled before you reach retirement age. -National School Lunch Program is free or reduced meals at school. -Public Housing Assistance and Section 8 vouchers provide assistance with affordable housing. -Lifeline Program that provides free or low cost phone service

How did you hear about us?*

Other organizations include but are not limited to: YMCA, Boys and Girls Club, your School District, your local government, etc.

Other*

Name of School District*

Name of Friend/Family *

Please enter first and last name

Please confirm how you would like human-I-T to contact you / Por favor confirme cómo le gustaría que human-I-T se contacte con usted: *

Note: Message and data rates may apply / Nota: Se pueden aplicar tarifas de mensajes y datos
Text "Stop" at any time to opt-out of messages / Envía "Stop" en cualquier momento para cancelar la suscripción a estos mensajes

Check if you would NOT like to receive future news, events and information from human-I-T

Opt-out

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Campaign Medium

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Campaign Term

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Campaign Content

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Campaign Name

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GCLID (Google Click Identifier)

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