Agent Onboarding Form

Master Agent Name(Required)

Distributor(Required)

Retailer(Required)

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

RAD ID(Required)

Register @ https://www.usac.org/about/affordable-connectivity-program/participate-in-acp/rad-registration/

Last 4 of SSN(Required)