LIFELINE/ACP Enrollment Application (ALABAMA, WISCONSIN, NORTH DAKOTA, MINNISOTA, MICHIGAN ONLY)

What State do you live in? *
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Valid Email Address*
example@example.com
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 of your Social Security Number*
What Federal Assistance program are you currently enrolled in?*

SNAP (Food Stamps)MedicaidSSISection 8WICVeterans Pension or Survivor BenefitsLow-Income (Proof of Income needed)
If qualifying through Low-Income, upload required documents.

Cancelof
What is the best way to reach you?*

EmailPhoneEither
If so, what Provider are you currently with?
I understand, as part of this Lifeline Service, I will receive Unlimited Talk, Unlimited Text, & 5GB of High Speed Data per month w/ a Free SIM Card.*
If currently enrolled in Lifeline through another provider, I consent to apply and/or transfer my Lifeline Benefits to nxxt or one of it's affiliates.*
If transferring your Lifeline benefit, you may not be eligible to transfer your service until next month unless you qualify under one of these exceptions.

You believe that an internet company transferred your benefit without providing you with the required disclosures and/or obtaining your consent to transfer your ACP benefit;Your household’s internet company stopped operating or failed to provide internet service; orYou moved to a location outside of your current internet company’s servicearea
(Check All Boxes) Lifeline Program*
(Check All Boxes) Transfer Benefits Consent*
Signature*

Powered by Jotform SignClear
Required information to transfer current phone number.
How did you find out about us?

FacebookInstagramFriend / Family memberOtherField Agent
SMS Messaging Policy:

By providing your mobile number and email address to NXXT MOBILE LLC, you consent to receive SMS (text) messages and emails from us for account-related notifications, service updates, promotional offers (if opted in), and customer support.

When you receive SMS messages from us, please note the following:

Consent: By opting in, you are expressly consenting to receive messages from NXXT MOBILE LLC at the number and email address provided.

Frequency: Message frequency may vary based on your activity with us. You may receive recurring messages.

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Help: Reply HELP for assistance or more information.

Rates: Message and data rates may apply depending on your mobile carrier and plan.

We use SMS solely to improve your experience and keep you informed. For questions or support related to messaging, please contact us at info@nxxtcom.com
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