User Register – American Loyal Wireless

Sign Up Application

Culture Wireless is an Authorized Reseller for major internet carriers in your area. Check if we have a provider in your area.

Tell us about your household

Create your Login Username and Password

username

password

What is your name?

First Name

Last Name

What is your phone number?

Phone number

What is your Home Address?

Street Address

city

state

zip

To verify your eligibility the EBB Program needs your Birthday & Last 4 Digits of your SSN?

YYYY

ssn

ssn2

SSN will only be used to verify your eligibility for the government benefit EBB program.

Tell us a little about you to help us create your account and determine eligibility

Do You Live with other adults?

Yes or no

Yes No

Do they get lifeline?

Yes or no

Yes No

How many people live in your household?

Household Size

agreement

I understand that the one-per-household limit is a Federal Communications Commission (FCC) rule and I will lose my Lifeline benefit if I break this rule.

What Gov Programs Do You Participate in? Check all that apply

Food Stamps, Reduced Price Lunch

Medicaid

Social Security Income

Veterans Pension

Federal Public Housing or Section 8

Qualify Based on Income / Unemployment (if selected)

Household income under poverty guidelines

Upload Proof Documents

Choose one of the following that contain you (or your dependent’s) full name, the qualifying program name, issuer and an expiration date if it wasn’t issue withing the last 12 months: Benefit Awards Letter, Approval Letter, Statement of Benefits, Benefit Verification Letter, StudentAid.gov screenshot

Upload Proof Documents

Choose one of the following that contain your full name and DOB: Social Security Number, US Driver’s License, US military ID, Passport, Taxpayer ID, Tribal ID

Tell us a little about you to help us create your account and determine eligibility

Choose the best installation time for us to setup your home internet in conjunction with AT&T

Preferred Home Internet Installation Time

Participation

By continuing with your application you are choosing to participate in the Emergency Broadband Benefit (EBB) Program. This offer provides UNLIMITED Data, Talk, and Text. Once the benefits are available, they will be automatically added to your account. This program will end after the Public Health Emergency no longer exists, or as deemed by the FCC. Once the program is over, your plan will revert back to the standard Lifeline offer. You may also choose to keep this UNLIMITED plan but will be subject to the standard rates. We will notify you when there is a change to the program. As a participant, you may transfer the EBB Program benefit to another provider at any time. This is limited to one per household, and is subject to FCC approval.

One per house

I understand that the one-per-household limit is a Federal Communications Commission (FCC) rule and I will lose my Lifeline benefit if I break this rule.

Partnership

I understand that Culture Wireless LLC is working in partnership with City Communications in Woodstock, GA to provide you access to the EBB program.

transitition

I consent to apply and/or transfer my EBB Benefits to Culture Wireless and City Communications and and transition to Lifeline only service when the EBB Benefits ends. I understand I am under no obligation to purchase the unlimited service and will receive the free Lifeline service, if I qualify, after the EBB Benefits program ends.

Data

I authorize Culture Wireless, to collect, use and share your information, including but not limited to information required for the purpose of establishing eligibility for and enrolling in the program, and including, but not limited to, full name, address, date of birth, social security number, as well as other personal information provided during this process with (USAC) and other third parties needed to process your application.

EBB TEMP

I participate in the designated qualifying program or have income at or below the level specified above and will provide documentation of eligibility if required to do so. I affirm and understand that the EBB Program is a temporary Federal Government and depends on government funds.

Change eligible

I understand that I must notify Culture Wireless within 30 days if I no longer participate in the qualifying program or no longer meet the income criteria, if I or another member of my household obtains Lifeline service from another carrier, or, for any other reason, I no longer qualify for Lifeline. I acknowledge that I may not have multiple Lifeline Program benefits or EBB benefits with the same or different providers. I acknowledge that Culture Wireless and City Communications have clearly disclosed to me that I may obtain broadband service by the EBB program from any other participating provider of my choosing, and I may transfer my EBB enrollment to another provider at any time.

Usage

I understand I am required of the following: I may be required to recertify, or reverify my continued eligibility for benefits at any time, and failure to do so will result in the termination of my benefits. I am required to use my Culture Wireless and City Communications service at least once every 30 days, or my service will be suspended, subject to a 15 day period which I may use the service or contact Culture Wireless to confirm that I want to continue receiving their service.

Change eligible

If I change my address, I will provide my new address to Culture Wireless within 30 days. I acknowledge and consent that Culture Wireless may make calls, send emails, and/or send text messages to me at any telephone numbers associated with my account, including wireless and other personal telephone numbers that could result in charges to me.

Only one

My household will receive only one Lifeline and one EBB benefit and to the best of my knowledge, my household and/or spouse does not already receive a Lifeline benefit or EBB benefit. I do not share living expenses and income with any other adult who currently resides at my address and is receiving Lifeline or EBB Benefits.

Correct Info

The information contained in this application and agreement is true and accurate to the best of my knowledge, and I acknowledge that providing false or fraudulent information to obtain benefits is punishable by law. I understand that the date of my application shall be based upon when I became eligible to receive service at provider’s sole discretion. I have been truthful regarding my status as a resident of Tribal lands, as defined in this form.

Authorization

I authorize Culture Wireless or its duly appointed representative to: (1) access any records to verify my statements herein; (2) to confirm my continued eligibility for; (3) to update my address to a proper format; (4) to provide any and all of the information related to my account including but not limited to my name and address to the Universal Service Administrative Company (USAC) and/or its agents for the purpose of verifying that I only receive one Lifeline and EBB benefit; and (5) authorize social service agency representatives to discuss with and/or provide information to Q Link Wireless verifying my participation in benefit program(s) that qualifies me for assistance.

Transmit

I consent that Culture Wireless may transmit the following information to the Universal Service Administrative Company (USAC) for the proper administration of the EBB program: my full name, full residential address, date of birth, the telephone number associated with my EBB service, the date on which my EBB discount benefit started, the date on which my EBB discount benefit ended, if it has ended, the amount of support required for my account and how I qualified for the EBB program. Failure to provide consent will result in me being denied the EBB service and/or the connected device benefit.

Electronically Sign

Sign

$20

UNL Highspeed Broadband Internet (w/ installation)

$10

25GB Highspeed Wireless Service (SIM card)

5GB Highspeed Wireless Service (SIM card)

Welcome. Tell us a little bit about you

Create your Login Username and Password

username

password

What is your name?

First Name

Last Name

What is your phone number?

Phone number

What is your Home Address?

Street Address

city

state

zip

To verify your eligibility the EBB Program needs your Birthday & Last 4 Digits of your SSN?

YYYY

ssn

ssn2

SSN will only be used to verify your eligibility for the government benefit EBB program.

Choose the best installation time for us to setup your home internet in conjunction with AT&T

Preferred Home Internet Installation Time

How did you hear about us?

Tell Us about Your Household

Do You Live with other adults?

Yes or no

Yes No

Do they get lifeline?

Yes or no

Yes No

agreement

I understand that the one-per-household limit is a Federal Communications Commission (FCC) rule and I will lose my Lifeline benefit if I break this rule.

What Gov Programs Do You Participate in? Check all that apply

Food Stamps, Reduced Price Lunch

Medicaid

Social Security Income

Veterans Pension

Federal Public Housing or Section 8

Qualify Based on Income / Unemployment (if selected)

How many people live in your household

Household Size

Review the Gov Program to get this discounted internet service

Participation

One per house

I understand that the one-per-household limit is a Federal Communications Commission (FCC) rule and I will lose my Lifeline benefit if I break this rule.

Partnership

I understand that Culture Wireless LLC is working in partnership with City Communications in Woodstock, GA to provide you access to the EBB program.

transitition

Data

EBB TEMP

Change eligible

Usage

Change eligible

Only one

Correct Info

Authorization

Transmit

Electronically Sign

Sign

*The Emergency Broadband Benefit (EBB) is a limited-time program that provides discounts on monthly Broadband Internet access service and certain connected devices, with a start date of May 12, 2021. EBB Program discounts are funded by the US Government’s Coronavirus relief effort and administered by the Federal Communications Commission (FCC). The EBB monthly service and device discounts are non-transferable. Eligible households are limited to one monthly service discount and one device discount. Eligible subscribers may obtain EBB-supported broadband service from any participating provider of their choosing and a subscriber can transfer their Emergency Broadband Benefit to another provider at any time. Once the program ends you will be notified. This is a limited-time offer that is subject to product availability. Terms & Conditions apply.*

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