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ACP Program Application

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Affordable Connectivity Program Application
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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Address Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Are you a recipient of Government Assistance Programs SNAP, WIC, Housing Help Please enter valid data.
- Are you eligible for Government Assistance ( SNAP, WIC, Housing Help REQUIRED Please fill out this field. Please enter valid data.
- Do you have anyone under the age 18 in the home? REQUIRED Please fill out this field. Please enter valid data.
- How many children are in the home? REQUIRED Please fill out this field. Please enter valid data.
- Are you in need of Technical Devices in the Home? REQUIRED Please fill out this field. Please enter valid data.
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