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Our Mission is to Provide the

Best Possible Service at the Lowest Possible Price.

Our Mission is to Provide the Best Possible Service at the Lowest Possible Price.

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CLGW ACP Enrollment Form

Customers must first qualify for eligibility at www.acpbenefit.org
Information below must match the information entered at www.acpbenefit.org or your approval for funds may be delayed.

Application Form

* = required

Application ID: (from your online enrollment account)
*

First Name:
*

Middle Name:

Last Name:
*

Date of Birth:
*

Last 4 Digits of SSN:
*

Did you use your DL# for the online process?

Service Address:
*

Mailing Address:
*

Email Address:
*

Phone Number:
*

Service Type:
   FIBER OPTIC INTERNET

If you qualify for the ACP program because of another person in your household please provide the following.

First Name:

Middle Name:

Last Name:

Date of Birth:

Last 4 Digits of SSN:

School Name if qualifying through free and reduced lunch provision:


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