Full Legal Name
Date of Birth* Social Security Number (SSN) (Last 4 Digits)* Email Address* Additional Information Driving LicenseGovernment ID Driving License / Government ID Attachment
By signing, I affirm that I understand the Affordable Connectivity Program is an FCC benefit program designed to provide free wireless connectivity and a discounted internet-enabled device upon eligibility. I acknowledge that the program is limited to one device discount per household. I hereby authorize Rivertel to apply for the ACP benefit on my behalf and upon approval, provide me with connectivity and if eligible, a discounted internet-enabled device from Rivertel Inc.
