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IJ Wireless Joining Consent

1. What is your full legal name?

The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

2. Your Phone Number?

3. Your Date Of Birth?

4. Your Email

5. Identity Confirmation. Please select one of the following:

(a) What are the last four digits of your Social Security Number (SSN)? If you did not provide your SSN or Tribal ID upon enrollment, please enter 0000.

OR

(b) What is your Tribal ID? I do not have a Social Security Number and was enrolled with my Tribal ID.

6. What is your home address? (The address where you will get service. Do not use a P.O. Box.)

7. Do you live on Tribal lands ?
Yes

No

8. Check all programs that you or someone in your household have:

Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps)

Supplemental Security Income (SSI)

Medicaid

Federal Public Housing Assistance (FPHA)

Federal Pell Grant for the current award year

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Free and Reduced Price School Lunch or Breakfast Program, or enrollment in a Community Eligibility Provision School. If you choose this program, please enter your school name, school district and state

Tribal Specific Programs
Bureau of Indian Affairs (BIA) General Assistance

Tribal Temporary Assistance for Needy Families (Tribal TANF)

Food Distribution Program on Indian Reservations (FDPIR)

Tribal Head Start (only households that meet the income qualifying standard)

9. Upload document of your government assistance.

(Allowed file extensions are jpg, jpeg, jpe, gif, png, pdf)

10. Interested In ?

Sim Card Only

11. I (or my dependent or other person in my household) currently get benefits from the government program(s) listed on this form or my annual household income is 200% or less than the Federal Poverty Guidelines.

12. I agree that if I move I will give my internet company my new address within 30 days.

13. I give IJ Wireless, Inc. permission to enrol me for the first time and, if necessary, transfer my existing records rather than classifying me as a new subscriber.

14. I understand that I have to tell my internet company within 30 days if I do not qualify for the ACP 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 benefit.

15. If you got transferred out from IJ Wireless with in 30 days, we have the right to transfer you back.

16. I know that my household can only get one ACP benefit and, to the best of my knowledge, my household is not getting more than one ACP benefit. I understand that I can only receive one connected device (desktop, laptop, or tablet) through the ACP, even if I switch ACP companies.

17. 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 benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get ACP 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 Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an ACP benefit.

18. I consent that I am going to switch to a new service provider to upgrade my service for better plans and enhanced benefits.

19. For my household, I affirm and understand that the ACP is a 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 company’s undiscounted general rates, terms, and conditions if my household continues to subscribe to the service.

20. All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

21. I know that willingly giving false or fraudulent information to get ACP benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

December 19, 2023 6:04 pm -05

IJ Wireless Joining Consent Uploaded by IJ Wireless - sales17@ijwireless.com IP 2400:adcc:2105:b500:f48a:beda:f224:8925

OR