Registration Form Referring Agent Name Client Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you a senior citizen? Yes No Choose a Service * Make a Selection Smart Phone Tablet Internet - 100mbps - $0/mo Internet - 500mbps - $10-$30/mo Internet - 1 GIG - $30-$60/mo Home Phone - $10/mo Benefits you qualify for (check all that apply) * EBT/Snap/Food Stamps SSI (Supplemental Supply Income) Medicaid Veterans' Pension FPHA (Federal Public Housing Assistance) WIC Child or dependent participates in free or reduced school lunch Received a Federal Pell Grant in the current award year I want to qualify using my W2, 1099, tax return, or retirement benefits letter Household Size * 1 2 3 4 5 6 7 8 or more Who is your current internet provider? * I do not currently have home internet AT&T Frontier Spectrum Xfinity Other Thank you for your submission!