Skinny Jump Application Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We will send you an automated copy of your responses to the email address that you provide below, but before you answer each question please make sure you read the explanatory details in each section about why we (Digital Inclusion Alliance and Stepping UP) are collecting this information and how we will use it.

In the first section, we need your name, address and contact details, so that if you meet the eligibility criteria we can send you a Skinny Jump modem. We may also use this information to contact you should we need to clarify any of your responses. This includes verifying that you are in a Skinny Jump coverage area.

This form may be completed by a Jump referral partner, with your information being provided by telephone.

Email *

First Name *

Last Name *

Street address (where Jump service is required) *

Suburb (where Jump service is required)

City or Town (where Jump service is required) *

Post Code (where Jump service is required)

Contact phone number: *

Would you like your Jump modem sent to the above address or to an alternative one? *

Yes, please send to the above address

No, please send to my alternative address below

Optional: Please enter an alternative address where we can courier your Jump modem; make sure you include a full physical address - number, street, suburb (or rural delivery) and town.

Is your home in a Skinny Jump coverage area? You must check this yourself at www.skinny.co.nz/jump. If the address checker indicates that you are not currently in coverage, we will double check for you and let you know the outcome. *

Yes, the Skinny Jump address checker confirms that I have coverage

No, I don't appear to be in a current Skinny Jump coverage area.

No coverage? Skinny Jump coverage areas are changing all the time, so if the address checker has indicated that you are not in coverage, do you want us to hold your application on file, or would your prefer to explore other options?

Yes, please keep my application on file in case my house does get coverage in the future

No, please cancel this application

Clear selection

Do you have a broadband internet service in your home? If "Yes", why do you need a Jump connection? *

Yes

Mobile phone only

Other:

Clear form

Never submit passwords through Google Forms.

This form was created inside of Digital Inclusion Alliance Aotearoa. Report Abuse

Forms