This signed Affordable Connectivity Program (ACP) Enrollment Form is required to enroll you in HES/energynet’s ACP
Program. The National Verifier, not HES/energynet, determines your eligibility to receive ACP. Only persons who
have been determined to be eligible by the National Verifier, or are currently receiving the Lifeline discount through
HES/energynet, should complete this Enrollment Form. If you do not currently receive the Lifeline discount and
have not qualified for ACP through the National Verifier, please visit www.affordableconnectivity.gov to apply.
The information you enter on this Enrollment Form must be exactly the same as what you provided the National Verifier to receive eligibility approval, which expires after 45 days. Submitting this form does not guarantee an immediate ACP discount with HES/energynet.
*Indicates a field that must be completed.
*You may file complaint against your provider via the FCC Consumer Complaint Center. For more information, click here.