Affordable Connectivity Program Please enable JavaScript in your browser to complete this form.Account Number *Full 16 Digit SECV Account number.USAC Application Approval ID *Example: Z54321-12345Name *FirstMiddleLastThe name you use on official documents, like your Social Security Card or State ID. Not a nickname.Email *Telephone NumberDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have a Social Security Number?YesNoSocial Security Number (Last 4 Digits) *Tribal Identification Number *Installation Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCannot be a PO Box, must be a physical AddressBilling Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre you qualifying through a child or dependent in your household?YesNoName *FirstMiddleLastThe name you use on official documents, like your Social Security Card or State ID. Not a nickname.Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does the qualifying dependent have a Social Security NumberYesNoWhat are the last 4 numbers of their Social Security Number (SSN)?What is their Tribal Identification Number? *Is the qualifying person enrolled with a free/reduce breakfast or lunch program?YesNoSchool *Internet Package *100 M (Up to 100 Mbps Download & 20 Mbps Upload)200M (Up to 200 Mbps Download & 20 Mbps Upload)300M (Up to 300 Mbps Download & 30 Mbps Upload)400M (Up to 400 Mbps Download & 40 Mbps Upload)600M (Up to 600 Mbps Download & 50 Mbps Upload)1Gig (Up to 940 Mbps Download & 50 Mbps Upload)2Gig (Up to 2,000 Mbps Download & 150 Mbps Upload)Continue