NV Eligibility - Qualification

Affordable Connectivity Program Application

Complete the form below and then click submit. Your information will be verified with the National Verifier and you will receive a response telling you what to do next.

If you need assistance please call 877-218-5744.

* This information is required.

What is your Legal name?
First Name *	Last Name *
Identity Verification
Date of Birth *	Last 4 digits of SSN *
Where do you live?
Tribal Benefit Flag *	Physical Address *
City *	State *
Zip Code *
Contact Information
Is Mailing Address different from Physical Address?
Mailing Address * Mailing City * Mailing State * Mailing Zip Code *
Consumer Email	Contact Phone Number

Program Eligibility

Eligibility Code
*

Do you Qualify for ACP through your child or a Dependent?

Child or dependent First Name

Child or dependent Last Name

Child or dependent DOB

Child or dependent Last 4 SSN

School Lunch Exception

School Name

I certify that if the consumer's household is being enrolled using the alternative verification process for households that receive a free/reduced price school breakfast or lunch, I have relied on information provided by a school for eligibility verification and that my company retains documentation indicating: the school providing the information; the program(s) that the school participates in; the household that qualifies (and qualifying student(s)); and, the program(s) the household participates in.

School Lunch Certification

BQP Tribal ID

Device Make

IMEI

Device Reimbursement Date

Verify Consent

I agree to have my personal information sent to the Nation Verifier for the purpose of applying for the Affordable Connectivity Program.

Consent
*

1. After you submit your application there may be a link that appears under the submit button. Click this right away to finish your application!

2. Please SAVE your National Verifier ID because you will need it on the Enrollment Form(example NV Application ID) B12345-12345

3. Once you have Completed your ACP application you are Ready to Enroll in the ACP Program! Click here to enroll today selectelwireless.com/acp

Affordable Connectivity Program Application

Complete the form below and then click submit. Your information will be verified with the National Verifier and you will receive a response telling you what to do next.

If you need assistance please call 877-218-5744.

* This information is required.

What is your Legal name?

Identity Verification

Where do you live?

Contact Information

Program Eligibility

Do you Qualify for ACP through your child or a Dependent?

Verify Consent