What Is Your Address?

This is the address where you'll receive any orders we send to you

Address

City

Postal code

State

Is This A Temporary Address?

Where Can We Reach You?

Best Contact Number *

Email

By checking here, I certify that this is my own number. I agree to the terms & conditions , and consent to be contacted via email, phone, text message, and mail.

What Is Your Birthdate & SSN

Date of birth

Last 4 of SSN

How would you like to qualify for FREE phone service?

Select a program you participate in below: *

Qualify Through Your Income

How many people currently reside in your household? *

By continuing, I certify my annual household income is at or below the Maximum Yearly Income

Federal Public Housing Assistance or Section 8

Federal Public Housing Assistance Program

Information About Your Government Program

Is the program is listed under your child or another beneficiary

yes

No

Child or Beneficiary’s Information

Child or Beneficiary’s First Name

Child or Beneficiary’s Last Name

Child or Beneficiary’s Date of Birth

Child or Beneficiary’s Last 4 (SSN)

Tell Us About your Household

Do you live with another adult? *

Tell Us About your Household

Do they get ACP (Affordable Connectivity Program) or Lifeline?

Tell Us About your Household

Do you share money (income and expenses) with them? *

I consent to apply and/or transfer my Lifeline and ACP benefits to Revolution Wireless. I understand I am under no obligation to purchase the unlimited service and will receive the free ACP service, if I qualify.

I understand that the one-per-household limit is a Federal Communications Commission (FCC) rule and I will lose my service benefits if I break this rule.

I consent to apply and/or transfer my Lifeline and ACP benefits to Revolution Wireless. I understand I am under no obligation to purchase the unlimited service and will receive the free ACP service, if I qualify.

I live at an address with more than one household And Agree to the Above

You Pre-Qualify For The ACP Program

The System decides what you qualify for but if given the choice:

Would You Like A Phone or Tablet? *

Sales Person Name *