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Submitted URL: https://jg5r39bq.r.us-east-1.awstrack.me/L0/https:%2F%2Fairtalkwireless.com%2Fctransfer%2Fe%2FV0FUMTY5ODUxMjQ2Ng==%2Fw/1/0100018b77f711d8...
Effective URL: https://airtalkwireless.com/ctransfer/e/V0FUMTY5ODUxMjQ2Ng==/w
Submission: On October 31 via api from GB — Scanned from US
Effective URL: https://airtalkwireless.com/ctransfer/e/V0FUMTY5ODUxMjQ2Ng==/w
Submission: On October 31 via api from GB — Scanned from US
Form analysis 1 forms found in the DOM
<form id="general_info" autocomplete="off" class="ant-form ant-form-horizontal ant-form-large transfer">
<h1 class="ant-typography">Transfer Agreement</h1>
<div class="ant-typography">
<div>Your Enrollment ID: WAT1698512466<br>Your Name: TOMMIE BRECKENRIDGE</div>
</div>
<div class="ant-typography">Use this worksheet if you need to transfer your Lifeline benefit, but have been told that you need an exemption to make an additional transfer in this calendar month. <br><br>Please check the appropriate statement if
<b>one</b> of the exceptions below applies to your household:</div>
<div class="ant-form-item">
<div class="ant-row ant-form-item-row">
<div class="ant-col ant-form-item-control">
<div class="ant-form-item-control-input">
<div class="ant-form-item-control-input-content">
<div aria-required="true" class="ant-radio-group ant-radio-group-outline ant-radio-group-large box-check" id="general_info_exception_code">
<div class="ant-space ant-space-vertical" style="gap: 8px;">
<div class="ant-space-item" style=""><label class="ant-radio-wrapper ant-radio-wrapper-in-form-item"><span class="ant-radio"><input class="ant-radio-input" type="radio" value="TE1"><span class="ant-radio-inner"></span></span><span>You
believe that an internet company transferred your Lifeline benefit without providing you with the required disclosures and/or obtaining your consent to transfer your Lifeline benefit;</span></label></div>
<div class="ant-space-item" style=""><label class="ant-radio-wrapper ant-radio-wrapper-in-form-item"><span class="ant-radio"><input class="ant-radio-input" type="radio" value="TE2"><span
class="ant-radio-inner"></span></span><span>Your household’s internet company stopped operating or failed to provide internet service; or</span></label></div>
<div class="ant-space-item"><label class="ant-radio-wrapper ant-radio-wrapper-in-form-item"><span class="ant-radio"><input class="ant-radio-input" type="radio" value="TE4"><span class="ant-radio-inner"></span></span><span>You moved to
a location outside of your current internet company’s service area.</span></label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="ant-form-item" style="margin-bottom: 0px;">
<div class="ant-row ant-form-item-row">
<div class="ant-col ant-form-item-control">
<div class="ant-form-item-control-input">
<div class="ant-form-item-control-input-content"><label class="ant-checkbox-wrapper ant-checkbox-wrapper-in-form-item"><span class="ant-checkbox"><input id="general_info_signature12" class="ant-checkbox-input" type="checkbox"><span
class="ant-checkbox-inner"></span></span><span>By checking this box, I confirm my agreement to the above statements</span></label></div>
</div>
</div>
</div>
</div>
<div class="ant-typography">By signing this form I, <b>TOMMIE BRECKENRIDGE</b>, acknowledge that after having reviewed these disclosures, I consent to transfer my household Lifeline benefit to AirTalk Wireless.</div>
<div class="ant-typography">By signing, you agree that the information you provided on this form is true and correct to the best of your knowledge.</div><br>
<div class="ant-row" style="margin-left: -12px; margin-right: -12px; row-gap: 24px;">
<div class="ant-col ant-col-12" style="padding-left: 12px; padding-right: 12px;"><b>Signature</b>
<div class="ant-typography">Enter your full legal name below</div>
<div class="ant-form-item">
<div class="ant-row ant-form-item-row">
<div class="ant-col ant-form-item-control">
<div class="ant-form-item-control-input">
<div class="ant-form-item-control-input-content"><input id="general_info_signature" aria-required="true" class="ant-input ant-input-lg" type="text" value=""></div>
</div>
</div>
</div>
</div>
<div class="ant-typography">
<div>Your Name: TOMMIE BRECKENRIDGE</div>
</div>
</div>
<div class="ant-col ant-col-12" style="padding-left: 12px; padding-right: 12px;"><b>Today’s Date</b>
<div class="ant-typography"> </div><span class="ant-input date">10/30/2023</span>
</div>
</div>
<div class="ant-row ant-row-space-between">
<div class="ant-col"><button type="submit" class="ant-btn ant-btn-round ant-btn-default ant-btn-lg"><span>Continue</span></button></div>
</div>
</form>Text Content
Hi there! Please enable Javascript in your browser to use Ant Design, Out-of-the-box mid-stage front/design solution! * About Our Program * Free Phone * Shop * My Service * Why AirTalk? * Help Center * My State * Check Coverage * Find A Store * * Login * Apply TRANSFER AGREEMENT Your Enrollment ID: WAT1698512466 Your Name: TOMMIE BRECKENRIDGE Use this worksheet if you need to transfer your Lifeline benefit, but have been told that you need an exemption to make an additional transfer in this calendar month. Please check the appropriate statement if one of the exceptions below applies to your household: You believe that an internet company transferred your Lifeline benefit without providing you with the required disclosures and/or obtaining your consent to transfer your Lifeline benefit; Your household’s internet company stopped operating or failed to provide internet service; or You moved to a location outside of your current internet company’s service area. By checking this box, I confirm my agreement to the above statements By signing this form I, TOMMIE BRECKENRIDGE, acknowledge that after having reviewed these disclosures, I consent to transfer my household Lifeline benefit to AirTalk Wireless. By signing, you agree that the information you provided on this form is true and correct to the best of your knowledge. Signature Enter your full legal name below Your Name: TOMMIE BRECKENRIDGE Today’s Date 10/30/2023 Continue * Email: info@airtalkwireless.com * Contact Us: +1 (855) 924-7825 * Monday - Friday: 8:00 a.m. – 8:00 p.m. CST Saturday: 10:00 a.m. - 7:00 p.m. CST * * * * * SHOP * Free Phone * Upgrade Phone * Tablet * Hotspot * International Calling * Bring Your Own Device OUR SERVICES * Blog * Sign Up For ACP * Lifeline Program * Sign In * Upload Proof * Check Status * Find a Store HELP CENTER * About AirTalk Wireless * Common Questions * Application * Account * Tracking Number * Upload Proof * Government Programs * Contact DOWNLOAD OUR APP WITH A SMART DEVICE Download on the App Store Get it on Google Play Copyright © 2023 AirTalk Wireless All Rights Reserved * Privacy Policy | * Terms & Conditions | * Law Enforcement | * Open Internet Statement | * Hearing Aid Compatible Devices Chat with us, powered by LiveChat