Nortex Affordable Connectivity Program Opt-In and ConsentForm

Date*

Customer Name*

First Last

Physical Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email Address*

Customer must read and check all applicable statements below. Failure to fully accept all program statements may result in disqualification from the Affordable Connectivity Program (ACP):*

I hereby opt-in to the Affordable Connectivity Program (ACP).

I understand that I may obtain broadband internet access service from any participating provider of my choosing, and that I may transfer my ACP benefit to another provider at any time, but at this time, I consent to applying my ACP benefit to the broadband internet access service I receive from Nortex.

I certify that I: 1) have confirmed my eligibility for the ACP through the National Verifier; OR 2) meet the eligibility standards as a current federal Lifeline program beneficiary recipient

I have received approval for the Affordable Connectivity Program through the National Verifier. My Application ID is:

I consent to Nortex transmitting all information required to ensure in the ACP. This information may include me or my eligible dependent’s name, mailing and primary address, date of birth, telephone number, ACP discount amount, eligible program, service type, service initiation date, service termination date, last 4 digits of social security number, LinkUp Date, and Independent Economic Household certification date.

I understand that 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 a broadband benefit under the FCC's ACP.

I understand that if I share an address with one or more existing ACP subscribers according to the National Lifeline Accountability Database or National Verifier, I must complete a form certifying compliance with the one-per-household rule prior to initial enrollment in the program.

I understand that the ACP amount will be issued as a monthly discount on my broadband internet access service, and that the benefit amount will not exceed Nortex’s standard rate for my broadband internet access service.

I consent to Nortex verifying my household’s broadband usage each month to enable Nortex to claim reimbursement for my program benefit each month.

I understand that if Nortex has a reasonable basis to believe that I am no longer eligible to receive the ACP, I will receive a notification of impending termination of my ACP, and will have 30 days following the date of such notice to demonstrate continued eligibility.

I understand that I will not be required to pay early termination fees if I choose to terminate or modify my broadband service during my participation in ACP, or upon receiving notice of the benefit ending.

I understand that unless otherwise stated herein, my participation in the ACP does not alleviate my obligations to adhere to Nortex’s posted Rates, Terms and Conditions, filed Tariffs, Acceptable Use Policy or other rules and regulations that govern the services I receive.

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Nortex Affordable Connectivity Program Opt-In and ConsentForm

Nortex ACP Opt-In and Consent Form

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