Equipment Distribution Program Application

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This field is for validation purposes and should be left unchanged.

First Name*

Last Name*

Gender*

Date of Birth*

Physical Address

Street Address*

Address Line 2

City*

State

Zip / Postal Code*

County*

Phone Number*

Email

Race*

Ethnicity*

Are you willing to upload optional supporting documentation?*

Including proof of Nevada residency and/or proof of disability.

Proof of Nevada Residency

Note: The following documents are accepted:

Nevada Driver's License
Nevada State Identification
Utility Bill

Upload file for Proof of Nevada Residency

Drop files here or

Max. file size: 8 MB.

Acceptable file types include .jpg, .jpeg, .png, pdf, .doc, and .docx.

Proof of Disability

Note: The following documents are accepted:

Statement from a professional (school administrator, health care provider, medical professional, social security agent, or vocational rehabilitation counselor)
Audiograms
SSI/SSDI letters

Upload file for Proof of Disability

Drop files here or

Max. file size: 8 MB.

Acceptable file types include .jpg, .jpeg, .png, pdf, .doc, and .docx.

Would you like to subscribe to our mailing list?*

Program Agreement:

By applying for a communications device from the Reach Nevada, I agree to the following:

I understand that this program provides equipment only and does not cover the cost of wireless plans, telephone services, or internet services.
I agree to return my device to Reach Nevada if I move out of Nevada within 3 years.
I agree to return my device for repair if there is an issue within 3 years and understand the device may be covered under warranty.
I agree to notify Reach Nevada within 30 days of any changes to my address, phone number, or email.
By signing below, I certify that the information I’ve provided is true and accurate to the best of my knowledge, that I meet the eligibility criteria, and that I agree to the Terms and Conditions of the Reach Nevada.

Applicant Electronic Signature (Type Full Name)*

By typing my name below, I acknowledge that this constitutes my electronic signature and that it is legally binding, equivalent to my handwritten signature.

Online Application for Equipment Distribution Program