TRANSFER CONSENT FORM

TRANSFER BENFITS CONSENT FORM

By signing below, I agree to statements 1 - 5 below to confirm you have read and understand the disclosures related to the transfer of your Lifeline Program benefit to a nxxt affiliate.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
1. I acknowledge that my Lifeline Program benefit will be transferred to nxxt affiliate.

2. I understand that my Lifeline Program benefit will be applied to service from a nxxt affiliate and will no longer be applied to service retained by my previous provider.

3. I understand, as a result of transferring my Lifeline Program benefit to a nxxt affiliate, I may be subject to my previous provider’s undiscounted rates if I choose to retain service from that provider.

4. I understand that I cannot have multiple Lifeline Program benefits with the same or different service providers.

5. I acknowledge that I have received the disclosures related to my request to transfer my Lifeline Program benefit. I understand these disclosures and I consent to the transfer of my Lifeline benefit to a nxxt affiliate
PLEASE SIGN BELOW: I have read the Broadband Internet agreement carefully, fully understand its contents, and voluntarily agree to its terms. *

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TRANSFER BENFITS CONSENT FORM