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Applicant Information

Please complete the following with legal and valid information or else your application will not be accepted.


Please use the address you used to receive your government benefits. (P.O. Box is not valid)

Eliminate Your Co-Pay

The Affordable Connectivity Program requires each participant to make a one-time contribution of more than $10 and less than $50 to the ACP fund, but we have a non-profit that will happily make this contribution for you, or you can choose to pay it yourself.

I wish to use the non-profit donation for my co-pay
Internet payment option provided

Enrollment Consent

The Affordable Connectivity Program (ACP) is a federal government benefit that reduces the cost of broadband internet service for eligible consumers. Affordable Connectivity Program (ACP) benefits are strictly limited to one per eligible household (not one per person). ACP benefits cannot be transferred to another person or household. You may obtain ACP supported broadband service through any qualified, participating provider. You may transfer your ACP broadband service to another ACP provider at any time. If ACP is terminated, you or your household will be offered an opportunity to continue broadband service at a cost equal to the current commercial rate for such service. This form is used for the purpose of verifying your eligibility through NLAD (the National Verifier) as well as to enroll you in ACP benefits with an eligible Public Wireless service plan.

I understand ACP allows only one ACP benefit per household. I hereby certify to the best of my knowledge my household does not currently receive an ACP benefit. I consent to enroll or transfer into Public Wireless, LLC Affordable Connectivity Program.

Checking this box will serve as your digital signature.