Sign Up Form – Surge Link

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone *

Email Address *

Eligibility Basis (Select one or more) *MedicaidSupplemental Nutrition Assistance Program (SNAP/Food Stamps/WIC)Supplemental Security Income (SSI)Federal Public Housing AssistanceVeteran or Survivor PensionEligible Based on Income

National Verifier Application Info

National Verifier Application ID *

Click here if you need assistance obtaining your National Verifier Application IDNeed assistance

How many people in your household are in each age range?

Under 5 years old

5-18 years old

19-24 years old

25-44 years old

45-64 years old

65-74 years old

75 years old or above

Which category best describes you? Check all that apply. (i.e. Two or more races)White (Eg: German, Irish, English, Italian, Polish, French, etc)Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc)Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc)Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc)American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc)Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc)Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc)Some other race, ethnicity or origin (Please specify below)

Specify other race

How much education have people in your household completed? Please indicate only the highest level completed for each individual.

Less than high school or equivalent (GED)

High school degree or equivalent (GED)

Some college

Associate’s or Technical degree

Bachelor’s degree

Post-graduate (such as Master’s or Doctorate)

Are you or anyone in your household a veteran? (Ever served in the U.S. Armed Forces, Reserves, or National Guard)YesNoPrefer not to answer

Would you or anyone in your household be interested in taking digital skills training?YesNo

Please indicate which of the following internet-connected devices are in use in your household. Indicate the number of each:

Computers or laptops

Tablets (i.e., iPads, Kindles)

Smart phones

Smart appliances (internet enabled)

Game consoles

Internet enabled TV

Other

Do you speak a language other than English at home?YesNo

What language?

How well do you speak English?Very wellWellNot wellNot at all

Why are you interested in Surge Link? Please check all that apply.I did not have internet service beforeI am not satisfied with my current internet providerIt costs less than other optionsTech support is easy to accessFor other reasons (please specify)

Other activities

What kind of Internet connection do you have at home?Dial-upDSL (provided by landline telephone provider)Cable modem (provided by cable TV provider)Fixed Wireless (service from a tower to a small antenna on your house)CellularSatelliteFiberDo not know

Sign Up for Surge Link™

Upon submission of the form below, you will be notified with 3-5 business days of application approval.

Please make sure to enter the following information exactly as shown on your supporting documentation. If there is a slight difference (e.g. Using “Joe” instead of “Joseph”), it may delay approval.

Information requested within this form is collected for the intention of providing Surge Link service and evaluating the need for associated programming.