List Request Form

Please select the type of list you are requesting (select one). *

You MUST agree to each of the following statement below. No list will be provided if you do not agree. *

	Agree	Do Not Agree
I agree to follow all the National/State Do Not Call Lists and CMS regulations when using my list(s).
I agree to update Trusted Senior Specialists with a count of presentations and sales resulting from the use of my list(s).
I understand all telephone numbers provided by Trusted Senior Specialists can only be used through the end of the last day of the month in which I received my list(s). Use afterward may be in violation of the National/State Do Not Call Lists.

Name *

First Name Last Name

Email *

example@example.com

Mobile Phone Number *

Please enter a valid phone number.

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

I would like a list of people who are: (select all that apply) *

Turning _______ (age), from ________ (month) to _______ (month). Specific Age Group: from _______ years old to ______ (years old). Low Income (This includes an annual income range from $0 to $25,000). Specific Income Range from $ ______ to $ ______. Specific Ethnic Group: ___________________ (subject to availability).

Please enter the specific information that is missing from the field above (Example: if you are requesting a list for a Specific Age Group above, enter that range in this field.) *

Please list the geographical areas you are requesting. You must provide EITHER zip codes, counties, or cities. (Choose ONE of the Three Only) *

Additional Notes:

Disclaimer: By submitting this request, I understand and agree to all of the above conditions as indicated by my affirmative responses. I agree to take full responsibility and will not hold Trusted Senior Specialists, or any of its employees, responsible if I use this list improperly. I hereby agree that my signature below will serve the same purpose, and is just as binding, as if I had provided a handwritten signature on this order form. Please use the drop-down below and select one response. *

Signature *

Clear

Please select below to acknowledge the date you are signing/submitting this form. *

Date