Application Form for ACP Benefits & New Tablet Access

Your Information

All fields are required unless indicated otherwise.

1. Identity Verification.

Last 4 of Social

Zip Code

2. What is your full legal name?

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

First Middle (optional) Suffix (optional) Last

3. What is your phone number?

4. What is your date of birth?

5. What is your email address?

Address Information

All fields are required unless indicated otherwise.

* Tribal lands include any federally recognized Indian tribe’s reservation, Pueblo, or colony, including former reservations in Oklahoma; Alaska Native regions established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688) ; Indian allotments; Hawaiian Home Lands—areas held in trust for Native Hawaiians by the state of Hawaii, pursuant to the Hawaiian Homes Commission Act, 1920 July 9, 1921, 42 Stat. 108, et. seq., as amended; and any land designated as such by the FCC pursuant to the designation process in the FCC’s Lifeline rules. A map of qualifying Tribal lands is available) on USAC’s website:fcc_tribal_lands_map.pdf

6. What is your home address?

The address where you will get service. Do not use a P.O. Box

Street Number and Name Apt., Unit, etc City State

7. Is this a temporary address?

Yes

8. Do you live on Tribal Lands? ^*

Yes

9. Is Your Mailing Address the same as the Home Address above?

Yes, My Mailing Address is the same as the Home Address above.

No, My Mailing Address is different from the Home Address above.

What is your mailing address?

Only fill this out if it is not the same as your home address.

Street Number and Name Apt., Unit, etc City State Zip Code

Beneficiary Information

10. Are you qualifying through a child or dependent?

No, I am qualifying through myself.

Proceed to Step 14

Yes, I am qualifying through a dependent.

Only fill this section out if you are applying through a child or dependent.

11. What is your dependents full legal name?

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

First Middle (optional) Suffix (optional) Last

12. What is their date of birth?

13. Identity Verification.

Please select one of the following:

A. If you would like to verify their identity using a Social Security number.

Enter the last four digits of their Social Security number (SSN4)

B. If they have, and would like to use a Tribal Identification number to verify their identity.

Enter their Tribal Identification Number

C. If you would like to use a Driver's License, Military ID, Passport, or other Government ID to verify their identity.

Select the type of document you would like to use to verify their identity.

Driver's License

Military ID

Passport

Taxpayer Identification Number

Other Government ID

Please provide a scanned copy or photo of your form of identification.

ACP Qualification

You can qualify through certain government assistance programs or through your income (you do not need to qualify through both).

14. Choose one of the qualification methods.

Fill out this section to show that you, your dependent, or someone in your household qualifies for the ACP.

Qualify through a government program

Check the program that you or someone in your household have:

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

Supplemental Security Income (SSI)

Medicaid

Veterans Pension or Survivors Benefit Programs

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.

If you choose this program, please enter your school name, school district and state.

School Name School District School State

Qualify through your income.

Including you, how many people live in your household?

Is your income the same or less than the amount listed for your state and household size?

All 48 States, DC, and Territories $29,160

Alaska $36,420

Hawaii $33,540

Yes

200% of the 2023 Federal Poverty Guidelines
*The Federal Poverty Guidelines are typically updated at the end of January

Agreement

ACP Disclosures, Consents and Certifications

The Affordable Connectivity Program (ACP) is a government benefit program operated by the Federal Communications Commission (FCC) that provides discounts on monthly broadband Internet access service and certain connected devices. For more information about the ACP and program eligibility requirements, call us at 1-888-200-1076 or visit www.whoopconnect.com/what-is-acp/.

ACP discounts can be applied to any available Whoop Connect, Inc d/b/a Whoop Connect (Whoop Connect)’s service plans at the same terms available to households that are not eligible for ACP supported services. Upload/download speeds will be determined by your particular service plan, and other factors, including your device, network availability from our underlying carrier, your proximity to cellular towers, and environmental factors may affect speeds, as described in our Broadband Transparency Disclosure at www.whoopconnect.com/transparency-policy. A complete listing of our plans, including plans that are fully covered (no co-pay after application of the ACP discount), is available www.whoopconnect.com/.

Whoop Connect’s complete Terms and Conditions, including the Acceptable Use Policy, Privacy Policy and ACP Terms and Conditions, are available at www.whoopconnect.com/. You agree that your service will be activated upon submission of this application form and completion of the eligibility verification and enrollment process.

ACP monthly service and one-time device discounts are not transferrable to other households or individuals. ACP benefits may be obtained from any participating provider of your choosing.

An eligible household is limited to one monthly service discount and a single one-time device discount.

An eligible household does not have to purchase an ACP discounted connected device in order to enroll in the ACP and receive monthly service discounts.

Eligibility for the ACP, including Tribal benefits, is determined by the National Verifier and National Lifeline Accountability Database, administered by the Universal Service Administrative Company (USAC).

If the FCC announces the end of the ACP, we discontinue our ACP service offers, you transfer your ACP benefits to another provider, or we determine your household is no longer eligible, you will be notified. You may keep your service plan by paying the applicable undiscounted rate plus applicable fees and taxes.

If you select a plan that is not fully covered by applicable discounts and requires monthly post-payments, Whoop Connect may disconnect your ACP-supported service after 90 consecutive days of non-payment. A household may file a complaint against an ACP service provider via the FCC’s Consumer Complaint Center.

You authorize Whoop Connect and its contracted partners, including CGM LLC , to collect, use, share, and retain your personal information, including but not limited to information required for the purpose of establishing eligibility for and enrolling in ACP, or waste/fraud/abuse prevention, and including, but not limited to, full name, full residential address, date of birth, last four digits of social security number, phone number, eligibility criteria and status, the date on which any ACP service discount was initiated and if applicable, terminated, device information, usage status and other compliance requirements, the amount of support being sought for the service, and information necessary to establish identity and verifiable address. This information may be shared with USAC to ensure proper administration of the ACP. Failure to provide consent will result in me being denied ACP connect device and service benefits.

I hereby certify that I have read, understand and consent to the disclosures listed above regarding the ACP benefits and consent to enroll in the ACP with Whoop Connect.

ACP Benefit Transfer Consent

A subscriber already enrolled in the ACP with another provider must consent to the transfer of their ACP benefit to Whoop Connect.

The effect of an ACP benefit transfer is that your ACP benefit will be applied to Whoop Connect’s ACP service and will no longer be applied to service retained from your former ACP service provider. You may be subject to your former ACP provider’s undiscounted rates as a result of the transfer if you elect to maintain service from that provider.

If I am unable to transfer my service immediately, I authorize and consent to Whoop Connect to transfer my service on the 1st of the month when my transfer hold is released.

You are limited to one ACP benefit transfer transaction per service month, with limited exceptions for situations where a subscriber seeks to reverse an unauthorized benefit transfer or is unable to receive service from a specific provider.

I hereby certify that I have read, understand and consent to the disclosures listed above regarding the ACP benefit transfers and consent to and authorize Whoop Connect to transfer my current ACP benefit to Whoop Connect, if I am found to already be receiving an ACP discount benefit from another ACP provider.

ACP Discounted Connected Device Purchase Election

I agree that if I receive a connected device discount from Whoop Connect as part of the ACP, I will pay a minimum of $10.01 and a maximum of $49.99 for the connected device and that, to the best of my knowledge, no one in my household has received a connected device discount from any service provider through the ACP or the Emergency Broadband Benefit program.

I hereby certify that I have read, understand and consent to the disclosures listed above regarding the ACP connected devices and I hereby confirm that want to purchase and receive an ACP discounted connected device from Whoop Connect.

Certification of Truth and Correctness Under Penalty of Perjury

By checking this box, I hereby certify, under penalty of perjury, that the information included in the foregoing applications and certifications is true and correct to the best of my knowledge.

Consent to Receive Communications

I authorize and give express consent to being contacted via email, telephone, or text messaging, including calls or messages using an automated telephone dialing system, manually, or with pre-recorded/artificial voice messages.  We may contact you for service-related, informational or marketing purposes via these methods.  You also provide express consent to contact you, regardless of whether your number is listed on the Do-Not-Call Registry or a state equivalent registry.  Consent to such contacts is not a condition of service and may be revoked at any time. Consent for emails, calls and texts is optional and can be revoked at any time by dialing 611 from my Whoop Connect provided wireless number or by calling 1-888-200-1076 and revoking consent. However, I understand that opting out will not affect Whoop Connect’s ability to contact me with free notices and messages regarding ACP service and/or any other service or product via the methods listed herein. For more information see our Terms and Conditions and Privacy Policy at www.whoopconnect.com/.

I authorize and give express consent for Whoop Connect to use and share my Customer Proprietary Network Information (CPNI) for marketing purposes.  You have a right, and Whoop Connect has a duty, under federal law, to protect the confidentiality of CPNI.  CPNI is information made available to us solely by virtue of our relationship with you that relates to the type, quantity, destination, technical configuration, geolocation data, and amount of use of the telecommunications services you purchase from us, as well as information related to the billing for those services.  You will continue to receive Whoop Connect communications services if you choose to not consent.  Customer Proprietary Network Information (CPNI) is described in our Privacy Policy at www.whoopconnect.com/privacy/. You may withdraw your consent at any time by reaching us as described in our Privacy Policy.

ACP Suspension

You understand that new ACP enrollments have been suspended by the FCC as of February 8, 2024. By certifying below, you agree that if and when new ACP enrollments are permitted by the FCC, you consent to enroll in ACP with Whoop Connect.
I hereby certify that I have read, understand and consent to the disclosures listed above regarding the ACP benefits. I also understand that new ACP enrollments have been suspended by the FCC as of February 8, 2024, but if and when new ACP enrollments are permitted by the FCC, I consent to enroll in the ACP with Whoop Connect.

E-sign Certification

I consent to use of this electronic form. I understand I have the right to enroll in the service using non-electronic methods. I further understand that I have the right to withdraw this consent at any time prior to the activation of my service. Whoop Connect has advised me and I understand that I may request a paper copy of my contractual terms and associated fees or withdraw this consent by calling 1-888-200-1076.

Collect Payment

Enter your payment information.

Your Total is $11.00

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