Lifeline & ACP Agent Application

"*" indicates required fields

First Name*

Last Name*

Phone*

Email*

Address

Street Address City State/Region ZIP Code

Have you sold the Lifeline or ACP Program before?

Yes

Somewhat

If Yes: What carrier did you work for?

What previous Lifeline companies or ETCs have you worked with?

Notes, anything else we should know?

Optional

Kansas Wireless is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

I agree to receive other communications from Kansas Wireless.*

I agree to receive other communications from Kansas Wireless. In order to provide you the content requested, we need to store and process your personal data. If you consent to us storing your personal data for this purpose, please tick the checkbox below.

I agree to allow Kansas Wireless to store and process my personal data*

I agree to allow Kansas Wireless to store and process my personal data.

You may unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.

CAPTCHA