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.

Please note that we are NOT taking any new inquiries for the Lifeline Phone Program

First Name

Middle Name

Last Name

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

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

City

State

Zip

Personal Phone Number (business phone numbers are not accepted)

Personal Email Address (business email addresses are not accepted)

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?

What is the best way to contact you?

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

By Checking 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, phone number, email 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 providing a phone number and submitting this form you are consenting to be contacted by phone or SMS text message.

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.

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.

**Please note that we are NOT taking any new inquiries for the Lifeline Phone Program**

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Please note that we are NOT taking any new inquiries for the Lifeline Phone Program