HACLA - Section 8 - Formstack

HACLA - Section 8 Internet Request

Fill in your information below to qualify for low-cost internet.
Currently, there is a free Chromebook offer that is only available in select CA zip codes.

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

Please confirm if you would prefer to be contacted back via Text. A representative will respond back within two business days. Only select Phone Call if you are unable to communicate with us through text. (call back times can take longer than a week due to program popularity). Por favor, confirme si prefiere que nos contactemos con usted por medio de mensaje de texto. Un representante responderá dentro de dos días hábiles. Solo seleccione Llamada telefónica si no puede comunicarse con nosotros por mensaje de texto. (Los tiempos de devolución de llamadas podrán tardar más de una semana debido a la popularidad del programa)*

Campaign Source

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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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