NORTEX ACP OPT-IN AND CONSENT FORMDate(Required) MM slash DD slash YYYY Customer Name(Required)Physical Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number(Required)Email Address(Required) The Affordable Connectivity Program (ACP) is a Federal Communications Commission (FCC) program that replaces the Emergency Broadband Benefit Program (EBB Program) to help low-income households pay for internet service. 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):(Required) 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 recipientApplication ID(Required)Untitled(Required) 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 Nortex may disconnect my household’s Affordable Connectivity Program-supported service after 90 consecutive days of non-payment. 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 my household will be subject to Nortex’s undiscounted rates and general terms if the Affordable Connectivity Proram ends, if the consumer transfers their benefit to another provider but continues to receive service form the current provider, or upon de-enrollment from the Affordable Connectivity Program. 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. I understand that I may file a complaint against my provider via Commission’s Consumer Complaint Center: https://consumercomplaints.fcc.gov/hc/en-us/articles/4412582232980-Need-Help-with-an-Affordable-Connectivity-Program-ACP-or-Emergency-Broadband-Benefit-EBB-complaint-Signature(Required)CAPTCHA
