EBBP Application

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?*

Street Address

Apartment # or Suite #

City

State

Zip Code

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
10GB Plan

Upload a picture of your Government Assistance card/letter or you can send via text to (901) 614-0309 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 EBB 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 EBB Program benefit.
I know that my household can only get one EBB Program benefit and, to the best of my knowledge, my household is not getting more than one EBB Program benefit. I understand that I can only receive one connected device (desktop, laptop, or tablet) through the EBB Program, even if I switch EBB 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 EBB Program benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get EBB 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 EBB Program Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an EBB Program benefit.
For my household, I affirm and understand that the EBB 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 EBB 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 EBB 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 EBB Program benefit and regarding their choices within the EBB Program, and that the household provided affirmative consent to applying their Emergency Broadband Benefit to the service for which they are being enrolled.

Transfer Consent

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

FREE SurgePhone
10GB Data

USD$10.01

Shipping Street Address

Shipping Apartment # or Suite #

Shipping City

Shipping State

Shipping ZipCode

LEGAL NOTES
SurgePhone Wireless Emergency Broadband Benefit (EBB) offering is a supported service - a government benefit program. Only eligible consumers may enroll in EBB. EBB 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 EBB Mobile Broadband Plans require the purchase of a Mobile Broadband device discounted to $10.01 or require you to bring a compatible or unlocked device. Offers may not be available in all service areas. SurgePhone Wireless Mobile EBB 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 surgephone.com/terms-of-service/ shall apply.

The EBB is a temporary program operated by the Federal Communications Commission (FCC) that provides discounts on monthly broadband Internet access service and certain connected devices. EBB 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
10GB Plan

CONFIRMATION

Confirm and sign your application

FINAL STEP

Payment

FREE SurgePhone
10GB Data

USD$10.01

PERSONAL INFO

Let's start with your personal information

Qualify through your income:

Or

FREE SurgePhone Wireless Mobile 10GB Plan

CONFIRMATION

Confirm and sign your application

FINAL STEP

Payment

FREE SurgePhone 10GB Data

USD$10.01

FREE SurgePhone Wireless Mobile
10GB Plan

FREE SurgePhone
10GB Data