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San Jose Internet Pilot
Please fill out the below information and we will get back to you promptly.
The information collected through this form will only be used to determine potential participants in this pilot, and will not be shared with any other entities or programs.
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First Name
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Your answer
Are you 18 years of age or older? This program is limited to adults 18 years or older.
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Yes
No
What is your current zip code? (This program is limited to San Jose residents)
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Your answer
What is your phone number?
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Your answer
What is your e-mail address?
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Your answer
Are you interested in a learning about a program that provides residents free low-cost internet?
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Yes
No
Do you currently qualify for any of the following programs? Please check any that may apply.
Child Enrolled in the NSLP (National School Lunch Program)
CalFresh (food stamps) or Supplemental Nutrition Assistance Program (SNAP) Recipient
Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) Recipient
Medi-Cal Recipient
Household Income Under $70,000/year
No - do not qualify for any
Do you currently have internet enabled in your home?
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Yes
No
What is the best time for us to contact you?
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Morning
Afternoon
Evening
Additional Comments:
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