Service Electric Cablevision – Affordable Connectivity Program

Account Number *

Full 16 Digit SECV Account number.

USAC Application Approval ID *

Example: Z54321-12345

Name *

First

Middle

Last

The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

Email *

Telephone Number

Date of Birth *//

Do you have a Social Security Number?

Social Security Number (Last 4 Digits) *

Tribal Identification Number *

Installation Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cannot be a PO Box, must be a physical Address

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Are you qualifying through a child or dependent in your household?

Name *

First

Middle

Last

The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

Date of Birth *//

Does the qualifying dependent have a Social Security Number

What 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?

School *

Internet Package *