To apply for a Affordable Connectivity Program, fill out every section of this form, initial every agreement statement, and sign the last page.
Let’s start with your personal information
What is your full legal name?
The name you use on official documents, like your Social Security Card or State ID. Not a nickname.
Mandatory fields
First Name
Last Name
SSN (Last 4 digits)
Drivers License # / Government ID
Date of Birth
Contact Number
What is the best way to reach you?
Email
Phone
SMS
Mail
Who gets the government assistance like SNAP, MEDICAID etc
Myself
Somebody else in household
Affordable Connectivity Program (ACP) Consent
By clicking YES you affirm and understand that the Affordable Connectivity Program is an FCC benefit program that reduces your monthly Broadband invoice. The program will be in effect for an indefinite amount of time. At the conclusion of the program, you will be given 30 days' notice and may elect to keep your plan at an undiscounted rate. As a participant you may transfer your ACP benefit to another provider. The Affordable Connectivity Program is limited to one monthly service discount and one device discount per household.
Do you consent to enrollment or transfer into the Go MD USA Affordable Connectivity Program and do you understand that you are not allowed multiple ACP program benefits with the same or different providers?
1. I hereby certify that I'm receiving ACP benefits from another provider; however, with this application, I would like to transfer my benefits to Go MD USA
2. I hereby certify that to the best of my knowledge, my household is not already receiving ACP service benefits and would like to enroll for ACP benefits with Go MD USA
What is your home address?
Applicant Address/Service Address ( PO BOX is not allowed)
Mandatory fields
Street
Apt. #
Zip Code
City
State
@foreach ($states as $state)
@endforeach
The above address is your
Permanent Address
Temporary Address
Is Your Billing/Shipping address the same as the service address?
Yes
No
Qualify for Affordable Connectivity Program
Please select below to show that you, your dependent, or someone in your household qualifies for Affordable Connectivity Program. You can qualify for Affordable Connectivity Program by showing you already participate in one of the government assistance programs listed below. If you do not currently participate in one of the programs listed, you can choose to qualify based on your income. You will need to show proof of your participation in the program you choose or proof of income later in this application.
Medicaid
Supplemental Nutrition Assistance Program (SNAP) Food Stamps
Supplemental Security Income (SSI)
Federal Public Housing Assistance
Veterans Pension and Survivors Benefit Program
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Federal Pell Grant
Scool Lunch/Breakfast Program
Income Based Program