lifelineform

Lifeline Opt-In

"*" indicates required fields

MM slash DD slash YYYY
Name*
Date of Birth*
Address*
I certify that information contained on this form is true and correct to the best of my knowledge. I also certify:*
NOTE: THIS RECORD AND ANY RELATED DOCUMENTATION OF ELIGIBILITY MUST BE MAINTAINED FOR AS LONG AS THE SUBSCIBER RECEIVES LIFELINE BUT NO LESS THAN THREE FULL PRECEDING CALENDAR YEARS.