ACP Customer Enrollment Form

Affordable Connectivity Program- Customer Enrollment Form
By signing this form, I give my affirmative consent that I want to participate in the Emergency Broadband Benefit Program through Randolph Communications and its wholly-owned subsidiary Randolph Telephone Telecommunications Inc. that I understand and certify that:
1. Affordable Connectivity Program is a government program operated by the Federal Communications Commission that supports broadband services and connected devices to help low-income households stay connected during the COVID-19 pandemic.
2. I am either a current Lifeline customer or my eligibility has been verified by the National Verifier so that I qualify for the ACP. I may continue my Lifeline service if I choose not to enroll in the AC Program.
3. ACP provides a discount of up to $30 per month depending on price of the service tier or bundle. If the total bill exceeds $30 per month, I will be responsible for the remaining balance after the ACP discount is applied. This includes any taxes and required fees that are applied to the full amount of the service.
4. My existing Lifeline discount, if it is currently being applied to internet service, will be applied to my bill first, then the ACP credit will be applied.
5. My household may obtain broadband service supported by the ACP from any participating provider of my choosing and I may transfer my ACP benefit to another provider at any time.
6. I may choose to take ACP benefits from a service provider other than my existing Lifeline provider.
7. I may only receive one ACP benefit per household, from one participating provider, and I certify that no other member of my household is receiving an emergency broadband benefit under the ACP.
8. All official communications for ACP will be via electronic mail or text messaging and I consent to receive such communications from Randolph Communications.
9. I agree that all information I provide on this form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the ACP benefit. I understand that if this information is not provided to the ACP Program Administrator, I will not be able to get ACP benefits.
10. I will not be required to pay early termination fees if I choose to terminate or modify my broadband service during my participation in the ACP, or upon receiving notice of the benefit ending.
Electronic Signature:

By typing your name below, you agree that this is an electronic signature.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 Digits of Social Security*
Date of birth*
mm/dd/yy
Did you qualify through a dependent?*

YesNo
Email*
example@example.com
Signature with mouse/finger/stylus:*

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Date*

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Date
Should be Empty:

Affordable Connectivity Program- Customer Enrollment Form