ACP Pre-Registration

You are one step closer to getting connected to the resources you need.

Please complete the information below and you will be contacted by a representative as soon as possible.

We look forward to assisting you!

Which services are you initially interested in (select all that apply):

ASSISTANCE NEEDEDFREE TabletFREE Phone

I'VE ALREADY BEEN APPROVED OR CURRENTLY USE: (SKIP if not applicable)Lifeline (Phone)ACP (Tablet)

Name of current or previous Lifeline or ACP provider (if applicable)

ENTER INFORMATION HERE:

HOUSEHOLD APPLICANT INFORMATION

(One tablet per household. If there are more than one adult/household/child within the home, please select "ADDITIONAL HOUSEHOLD").

ARE YOU APPLYING FOR YOURSELF OR A CHILD? *MyselfChild

First Name *

Last Name

DATE OF BIRTH

LAST 4 DIGITS OF SSN *0 / 4

Email Address *

Phone Number *

Please insert the following information where the benefits are received.

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

ADULT APPLICANT RECEIVES THE FOLLOWING BENEFITS (upload a clear picture of each active benefit you receive)EBT/SNAPSCHOOL GOVT FREE LUNCHMEDICAIDPELL GRANTSSIWICVETERAN'S PENSIONVETERAN'S SURVIVOR BENEFITSGOVT HOUSINGMEDICAREUNEMPLOYMENT

UPLOAD PHOTO(S) OF BENEFITS

Drag and Drop (or) Choose Files

MINOR CHILD/CHILDREN

First Name

Middle Name

Last Name

DATE OF BIRTH

LAST 4 DIGITS OF SSN

NAME OF SCHOOL

SCHOOL DISTRICT

MINOR CHILD RECEIVES THE FOLLOWING BENEFITSEBT/SNAPSCHOOL GOVT FREE LUNCHMEDICAIDPELL GRANTSSIWIC

UPLOAD PHOTO(S) OF BENEFITS

Drag and Drop (or) Choose Files

Consent *

Yes, I agree to allow your organization to assist me in applying for the programs selected in my pre-application.

Please do not fill in this field.

CorZone Community Initiatives

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