Inquiry Form

If you would like Aloha Wireless to evaluate what services you may be eligible for, please fill out the following form and we will contact you to discuss what services or benefits may be available to you.

First Name

Middle Name

Last Name

Street Address (Residential USPS Verified Address, No PO Boxes)

Address Line 2 (Apt #, Unit #, Room #)

City

State

Zip

Phone Number

Email Address

Last Four Digits of Your Social Security Number

Date of Birth

Where Did You Hear About Us / Who Referred You?

What Government Program Are You Enrolled In?

Please attach your award letter or confirmation letter for any government benefit program you are enrolled in (optional).

By Clicking the Boxes Below, You are Agreeing to the Following Terms and Conditions.

I consent to the collection and use of my data, including name, address, date of birth, and the last 4 digits of my Social Security number by Aloha Wireless to determine eligibility for various discounted and government services.

By checking this box, I acknowledge and agree to the following: Purpose of Data Collection and Data Use: I understand that my personal data will be collected for the sole purpose of determining my eligibility for certain services provided by Aloha Wireless or its partners. Confidentiality and Security: I understand that Aloha Wireless will treat my personal data with confidentiality and implement reasonable security measures to protect it from unauthorized access, use, or disclosure. Data Retention: I understand that my personal data will be retained only for as long as necessary to fulfill the purpose for which it was collected unless a longer retention period is required by law. Right to Withdraw Consent: I have the right to withdraw my consent to the collection and use of my personal data at any time by contacting info@alohawireless.org.

By checking this box, I confirm that I have read, understood, and agree to the terms outlined above regarding the collection and use of my personal data for the purpose of reviewing my eligibility for the various discounted and government services.

Inquiry Form

If you would like Aloha Wireless to evaluate what services you may be eligible for, please fill out the following form and we will contact you to discuss what services or benefits may be available to you.

By checking this box, I confirm that I have read, understood, and agree to the terms outlined above regarding the collection and use of my personal data for the purpose of reviewing my eligibility for the various discounted and government services.

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