SurgePhone Application

CURRENTLY ENROLLED IN ACP?

TRANSFER YOUR BENEFITS & GET BETTER SERVICE!

NOT ACP ENROLLED?

Let's start with your personal information

Please use the name and address as spelled on your official Photo ID.

First Name*

Middle Initial

Last Name*

Suffix

Email Address*

Confirm Email*

Phone Number*

Secondary Phone

Last 4 numbers of your Social Security Number (SSN)?*

Date of birth?*

Zip Code*

Street Address*

Apartment # or Suite #

City*

State*

What is your shipping address? (Only fill this out if it is not the same as your home address.)

Shipping Street Address

Shipping Apartment # or Suite #

Shipping City

Shipping State

Shipping Zip Code

Qualifying Through Child or Dependent

Plan Details

FREE SurgePhone Wireless Mobile
5GB Plan

Upload a picture of your Government Assistance card/letter or you can send via text to 855-467-8743 or email to pob@surgephone.com

Click to add your Government ID*

Click to add your qualifying card*

Confirm and sign your application

I agree, under penalty of perjury,to the following statements:
(You must initial next to each statement.)
I (or my dependent or other person in my household) currently get benefits from the government program(s) listed on this form, experienced a substantial loss of income since February 29, 2020, or my annual household income is 135% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form).
I agree that if I move I will give my service provider my new address within 30 days.
I understand that I have to tell my service provider within 30 days if I do not qualify for the ACP Program anymore, including:
1.) I, or the person in my household that qualifies, do not qualify through a government program or income anymore.
2.) Either I or someone in my household gets more than one ACP Program benefit.
I know that my household can only get one ACP Program benefit and, to the best of my knowledge, my household is not getting more than one ACP Program benefit. I understand that I can only receive one connected device (desktop, laptop, or tablet) through the ACP Program, even if I switch ACP providers.
I agree that all of the information I provide on this form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the ACP Program benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get ACP Program benefits. If the laws of my state or Tribal government require it, I agree that the state or Tribal government may share information about my benefits for a qualifying program with the ACP Program Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an ACP Program benefit.
For my household, I affirm and understand that the ACP Program is a temporary federal government subsidy that reduces my broadband internet access service bill and at the conclusion of the program, my household will be subject to the provider's undiscounted general rates, terms, and conditions if my household continues to subscribe to the service.
All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.
I know that willingly giving false or fraudulent information to get ACP Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.
I was truthful about whether or not I am a resident of Tribal lands, as defined in the "Your Information" section of this form.

Subscriber eligibile for ACP Program, will be Transfer In on Enroll

I understand the provider's obligations under the FCC's rules and orders to ensure that the consumer was presented with clear disclosures regarding the ACP Program benefit and regarding their choices within the ACP Program, and that the household provided affirmative consent to applying their Affordable Connectivity Program to the service for which they are being enrolled.

Transfer Consent

The ACP is limited to one monthly service discount and one device discount per household. Your household cannot get the ACP Program benefit from more than one service provider at a time, and can only receive one connected device (desktop, laptop, or tablet) through the ACP Program, even if you switch ACP providers. You may transfer your Affordable Connectivity Program to another provider at any time. I understand the above and consent to transfer my household's existing Affordable Connectivity Program to SurgePhone Wireless Wireless LLC and will no longer receive ACP service with my previous provider.

Please sign to confirm and certify that you understand and acknowledge the above information:*
Using your mouse, hold down the left button on your mouse to draw your signature

Re-sign

Plan Details

SurgePhone Wireless ACP Monthly Service Plan 5GB 4G LTE Data Plus an 8” Android Tablet $11.00*

Description	Amount
Connected Device	$111.00
T-Mobile ACP 5GB Plan	$50
ACP One-Time Connected Device Credit	-$100.00
ACP Service credit	-$30
Company promo discount	-$20
Total: $11.00

*Final price of $11.00 is based on customer’s successful enrollment in the FCC Affordable Connected Program and eligibility of the one-time connected device credit. Visit FCC.gov/ACP for complete program rules.

Shipping Street Address

Shipping Apartment # or Suite #

Shipping City

Shipping State

Shipping ZipCode

LEGAL NOTES
SurgePhone Wireless Emergency Broadband Benefit (ACP) offering is a supported service - a government benefit program. Only eligible consumers may enroll in ACP. ACP service is limited to one per household and is non-transferable. Proof of income or qualified program participation may be required for enrollment. SurgePhone Wireless ACP Mobile Broadband Plans require the purchase of a Mobile Broadband device discounted to $11 or require you to bring a compatible or unlocked device. Offers may not be available in all service areas. SurgePhone Wireless Mobile ACP Plans are subject to the Terms and Conditions of Service found here. In the event of a conflict, the Terms and Conditions of Service at https://surgephone.com/terms-of-service/ shall apply.

The ACP is a temporary program operated by the Federal Communications Commission (FCC) that provides discounts on monthly broadband Internet access service and certain connected devices. ACP services and devices are subject to consumer eligibility, provider participation, product availability, and FCC/Universal Service Administrative Company (USAC) approval.

PERSONAL INFO

Let's start with your personal information

Qualify through your income:

Or

FREE SurgePhone Wireless Mobile
5GB Plan

CONFIRMATION

Confirm and sign your application

FINAL STEP

Payment

PERSONAL INFO

Let's start with your personal information

Qualify through your income:

Or

FREE SurgePhone Wireless Mobile 5GB Plan

CONFIRMATION

Confirm and sign your application

FINAL STEP

Payment

FREE SurgePhone Wireless Mobile
5GB Plan