Keep Your Service Active

Completion of this form is required. This form is used for the purpose of verifying your eligibility for and enrolling you in Lifeline benefits and an eligible IM Telecom (IM Telecom, LLC DBA Infiniti Mobile) service plan and will not be used for any other purpose. Lifeline benefits are subject to verification of eligibility by IM Telecom and the National Verifier or state Public Utilities Commission. Some restrictions may apply.

• 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. IM Telecom 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 (800) 615-0898.

First Name:
Middle Name:
Last Name:
Date of Birth:
Last Four SSN (or Tribal ID):

□ Is this a temporary address?

□ Check here if you live on Tribal lands.

Residential Street Address:
Apt:
City:
ST:
Zip:

Email Address:
Contact Number:

• By entering the phone number and email address above, I authorize and give express consent to being contacted by IM Telecom for marketing purposes during the Application Process. I may be contacted for this purpose via email, telephone, or text messaging, including calls or messages using an automated telephone dialing system, manually, or with pre-recorded/artificial voice messages. I also provide express consent to be contacted, regardless of whether my 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. Message and data rates may apply. Message frequency varies. For contacts received via text message, reply HELP for help or STOP to cancel, or click the unsubscribe link (where available) in any text message. I will receive a one-time opt-out confirmation text message. I may also revoke consent by calling (800) 615-0898, or by following the opt-out instructions in an email message. For more information see Terms and Conditions and Privacy Policy at www.getimtelecom.com.

IM Telecom service is a prepaid service offered by the company to subscribers eligible for Lifeline discount benefits in states where it is authorized to do so. I agree and acknowledge that my Lifeline service will be activated upon submitting the application form and completing the eligibility verification, enrollment and plan selection processes, as applicable. To keep your account active, you must use the service at least once during any 30-day period by completing an outbound call, sending a text message, using cellular data, purchasing additional service from IM Telecom, answering an in-bound call from someone other than IM Telecom, or by responding to a direct contact from IM Telecom confirming that you want to continue receiving service from IM Telecom. If your service goes unused for 30 days, you will no longer be eligible for Lifeline benefits and your service may be suspended (allowing only 911 calls and calls to the IM Telecom's customer care center) subject to a 15-day cure period during which you must use the service (as described above) in order to fully re-activate your service, keep your telephone number and remain enrolled in Lifeline.

I agree and acknowledge that my Lifeline service will be activated upon submitting the application form and completing the eligibility verification, enrollment and plan selection processes, as applicable. I understand that qualified Lifeline subscribers at the time of enrollment may be eligible to receive a free phone, purchase a phone, or get a free SIM card to use with their own device. Receipt of a free phone or the purchase of a phone is not guaranteed and may only be offered to qualifying subscribers. Plan offerings may vary by state and method of enrollment.

I understand that if I enroll in a plan that requires a monthly payment, IM Telecom may require a deposit at the time of enrollment. The deposit will be placed in my eWallet account and may be used to pay the monthly fee if payment is not received by the due date. I understand that I control any deposits placed in my eWallet account and may request a refund at any time. I may review the Terms and Conditions at www.getimtelecom.com to learn more about the refunding of unused balances in my account.

• I hereby certify that I have read and understood the disclosures listed above regarding activation and usage requirements.

Lifeline is a government benefit program operated by the Federal Communications Commission (FCC) that provides discounts on monthly broadband Internet access service and/or voice service. For more information about Lifeline and program eligibility requirements, call us at (800) 615-0898 or visit www.getimtelecom.com.

Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program.

Only one Lifeline benefit is available per household. A household is not permitted to receive discounted Lifeline services from multiple providers. A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses. Violation of the one-per-household limitation constitutes a violation of the FCC's rules and will result in you being de-enrolled from the Lifeline program.

Lifeline discount benefits are not transferrable to other households or persons.

Eligibility for Lifeline is determined by the National Verifier and National Lifeline Accountability Database, administered by the Universal Service Administrative Company (USAC), or an alternative verification process approved by the FCC. For more information about Lifeline and program eligibility requirements, call us at IM Telecom or visit www.getimtelecom.com.

IM Telecom’s complete Terms and Conditions, including our Acceptable Use and Privacy Policies, apply and are available at www.getimtelecom.com.

You authorize IM Telecom and its contracted partners 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 the Lifeline program, 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 Lifeline 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 Lifeline program. Failure to provide consent will result in me being denied Lifeline benefits and service.

• I hereby certify that I have read and understood the disclosures listed above regarding Lifeline benefits and consent to enroll in Lifeline with IM Telecom.

You are eligible for Lifeline based on which of the following criteria:

• Program eligibility: program

You acknowledge each of the certifications below individually and under penalty of perjury:

• I meet the income-based or program-based eligibility criteria for Lifeline in FCC rule 47 C.F.R. § 54.409;

• I will notify IM Telecom within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline including, as relevant, if I no longer meet the income-based or program-based criteria for receiving Lifeline support, I am receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit;

• If I am seeking to qualify for Lifeline as an eligible resident of Tribal lands, I live on Tribal lands, as defined in FCC rule 47 C.F.R. 54.400(e);

• If I move to a new address, I will provide that new address to IM Telecom within 30 days;

• My household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a Lifeline service;

• The information contained in this certification form is true and correct to the best of my knowledge;

• I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law; and

• I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify my continued eligibility will result in de-enrollment and the termination of my Lifeline benefits pursuant to FCC rule 47 C.F.R. § 54.405(e)(4).

A subscriber already enrolled in Lifeline with another provider must consent to the transfer of their Lifeline benefit to IM Telecom. The effect of a Lifeline benefit transfer is that your Lifeline benefit will be applied to IM Telecom’s Lifeline service and will no longer be applied to service retained from your former Lifeline service provider. You may be subject to your former Lifeline provider’s undiscounted rates as a result of the transfer if you elect to maintain service from that provider.

I understand and agree that, to prevent unauthorized transfers of my Lifeline service to another provider without my consent, IM Telecom may automatically transfer my service back to IM Telecom if such a transfer occurs within 120 days of my enrollment—unless I have given clear confirmation that I want the transfer to proceed. By enrolling, I consent to this automatic transfer-back policy. IM Telecom will notify me by text message and/or email if a transfer to another provider occurs within 120 days of enrollment. If I do not confirm the transfer within forty-eight (48) hours of receiving this notification, my Lifeline service will be restored to IM Telecom. I may revoke my consent to this 120-day automatic transfer-back policy at any time by contacting IM Telecom Customer Service at 1-800-615-0898. This policy does not apply to California LifeLine subscribers.

• After receiving and reviewing the foregoing required disclosures, I consent to and authorize IM Telecom to transfer my current Lifeline benefit to IM Telecom, if I am found to already be receiving a Lifeline discount benefit from another Lifeline provider.

• 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. I understand that willfully making false statements to obtain benefits may result in fines, imprisonment, de-enrollment, or being denied benefits.

• I authorize and give express consent to being contacted via email and telephone, including calls or messages using an automated telephone dialing system, manually, or with pre-recorded/artificial voice messages. IM Telecom may contact me for service-related, informational or marketing purposes, including offers from IM Telecom affiliates via these methods. I also provide express consent to be contacted, regardless of whether my 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 and calls is optional and can be revoked at any time by dialing 611 from my IM Telecom provided wireless number or by calling (800) 615-0898 and revoking consent. I understand that opting out will not affect IM Telecom’s ability to contact me with free notices and messages regarding my wireless service and devices and my Lifeline benefits via the methods listed herein. For more information, see the Terms and Conditions and Privacy Policy at www.getimtelecom.com.

• I authorize and give express consent to being contacted via text messaging. IM Telecom may contact me for service-related, informational or marketing purposes, including offers from IM Telecom affiliates via these methods. Consent to such contacts is not a condition of service and may be revoked at any time. Consent to receive texts is optional and can be revoked at any time by dialing 611 from my IM Telecom provided wireless number, by calling (800) 615-0898 and revoking consent, or by replying “STOP” or other appropriate command in reply to an incoming text message. I understand that opting out will not affect IM Telecom’s ability to contact me with free notices and messages regarding my wireless service and devices and my Lifeline benefits via the methods listed herein. For more information, see the Terms and Conditions and Privacy Policy at www.getimtelecom.com.

• I authorize and give express consent for IM Telecom to use and share my Customer Proprietary Network Information (CPNI) for marketing purposes. I have a right, and IM Telecom has a duty, under federal law, to protect the confidentiality of CPNI. CPNI is information made available to IM Telecom solely by virtue of IM Telecom’s relationship with me that relates to the type, quantity, destination, technical configuration, geolocation data, and amount of use of the telecommunications services I purchase from IM Telecom, as well as information related to the billing for those services. CPNI does not include subscriber list information, such as name, postal address, or telephone number. I will continue to receive IM Telecom communications services if I choose not to consent. CPNI is described in our Privacy Policy at www.getimtelecom.com. I may withdraw my consent at any time by using the contact information as described in the Privacy Policy.

• I certify under penalty of perjury that the information I submit is accurate to the best of my knowledge. I understand that willfully activating a new line with false or fraudulent information is punishable by law and may result in criminal prosecution. Furthermore, I understand that my name and signature will be retained as my attestation certifying to the best of my abilities the accuracy of each new enrollment submitted. I acknowledge that I am providing my information to CGM, LLC and authorize CGM, LLC to receive and use my information for enrollment verification and waste, fraud, and abuse mitigation purposes.

• I acknowledge that my application may require you to determine my eligibility for a benefit granted by a governmental instrumentality required by law to consider an applicant’s financial responsibility or status. As a result, I understand that you may request consumer reports for that purpose from CGM, LLC, located at 104 Sloan Street, Roswell, Georgia 30075, telephone number (888) 594-3860. These reports may include information from phone or internet providers regarding my service enrollment history, or the frequency with which I have received wireless devices, which may be used for enrollment verification and waste, fraud and abuse mitigation purposes.

• Notice to California Applicants: Under California Civil Code § 1786.22, you have the right to request from CGM, upon proper identification, the nature and substance of all information in files pertaining to you, including the sources of information, and recipients of any reports on you, which CGM has previously furnished within the three-year period preceding your request. You may view the file maintained on you by CGM during normal business hours. You may also obtain a copy of this file upon submitting proper identification. Upon making a written request, you may receive a summary of your report.

• I acknowledge that the information I have provided in this Consent to Obtain Consumer Reports is true and accurate. I certify that I have been provided with a copy of the Disclosure Concerning Consumer Reports which you may obtain about me in connection with my application. I have also been provided with a copy of the notice entitled “A Summary of Your Rights Under The Fair Credit Reporting Act.” I hereby consent to your gathering such information about me from CGM, LLC or any other agent you or CGM, LLC authorize, and to receive and use my historic ACP or Lifeline enrollment information for enrollment verification and waste, fraud, and abuse mitigation purposes.