Connected for Success application form

Please fill out this form to confirm your eligibility for the Rogers Connected for Success program.
You’re currently applying in Ontario.
If you’d like to apply in a different province, please change the province at the top of the page. Some requirements may change.

Address

Eligibility

Upload income support document(s)

To protect your privacy, please remove your Social Insurance Number (SIN) or Old Age Security (OAS) number from your documents before uploading. Please ensure that your name, address and the contents of Box 21 are clearly visible.
Note: upload your income support document(s). Supported file types include .pdf, .jpg, .png, .tiff and .heic.
Redact SIN or OAS number removal
Services you're interested in (subject to service availability): Services you're interested in (subject to service availability):

Add an authorized user (optional)

If you’re designating a third party or family member to assist with account setup and maintenance, please fill out this section to add them as an authorized user on your account by checking the boxes in this section.
An authorized user is allowed to make changes to your Rogers account, but not cancel your service. You can withdraw this authorization at any time by contacting us.
By proceeding with this application, I confirm that I am the person named in the application and am providing consent for the authorized contact/organization named below to activate my account on my behalf.
Acknowledgement & e-signature

Almost done!

Is there any additional information that you think would be helpful for us to know before reaching out to you?
By clicking submit, you acknowledge that your personal information will be treated in accordance with the Rogers Privacy Policy, which can be found at rogers.com/privacy.