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

1
What State do you live in? * This field is required.We only offer service in the below states currently.
Please Select
Please Select
Alabama
Florida
North Dakota
South Dakota
Minnesota
Michigan
New York
Montana
Wisconsin
Wyoming
I do not live in any of the above.
2
Are you currently receiving any of the following* This field is required.
SNAP (Food Stamps)
Medicaid
SSI
Section 8 (Federal Public Housing Assistance)
Veterans Pension or Survivor Benefits
3
Based on your answers, you may qualify for $0 monthly phone service through the Federal Lifeline Program. Please complete enrollment below.
4
What is your First and Last Name* This field is required.
First Name
Last Name
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Valid Email Address* This field is required.
example@example.com
8
Residential Address* This field is required.Residential Address Only
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Last 4 of your Social Security Number* This field is required.For identity verification only. This information is securely processed for federal program eligibility.
10
What is the best way to reach you?* This field is required.
Email
Phone
Either
11
I understand, as part of this Lifeline Service, I will receive Unlimited Talk, Unlimited Text, & High Speed Data per month w/ a Free SIM Card.* This field is required.TYPE YOUR NAME
12
If currently enrolled in Lifeline through another provider, I consent to apply and/or transfer my Lifeline Benefits to a nxxt affiliate ETC.* This field is required.TYPE YOUR NAME
13
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; or
You moved to a location outside of your current internet company’s servicearea
14
(Check All Boxes) Lifeline Program* This field is required.I certify, under penalty of perjury that:
15
(Check All Boxes) Transfer Benefits Consent* This field is required.I certify, under penalty of perjury that:
16
Signature (I certify under penalty of perjury that the information provided is true and correct and that I am requesting this transfer of my Lifeline benefit.)* This field is required.
Powered by Jotform SignClear
17
How did you find out about us?
Facebook
Instagram
Friend / Family member
Other
Field Agent
18
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.

Opt-Out: You may reply STOP at any time to unsubscribe from further messaging.
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
Should be Empty: