Free Phone & Tablets Registration Form

BACI will be distributing free phones & tablets for individuals who are qualify. Most people who are receiving Medicaid and/or SNAP qualify for free phones and tablets. Come check to see if you qualify.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Phone *

Email

What is the name of your religious congregation? Example: Church Name, Temple Name, Mosque Name, etc., if not N/A. (Note: this is not part of eligibility criteria, just for information for data recording purpose.) *

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Choose a pick up date *

• 01/08/2024
• 01/09/2024
• 01/10/2024
• 01/11/2024
• 01/12/2024

Are you a recipient of the following social benefits? *

• SNAP or food stamp
• Medicaid or Medicare
• None

Please bring proof of ID and card/documents for the above social benefit that you receive.

Submit

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