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.
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.
Mobile Phone Number
Please enter a valid phone number.
Street Address Line 2
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)
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.
I agree to the above disclaimer. Please send my requested list(s).
I do not agree to the above disclaimer. I do not wish to receive any list(s) at this time.
Please select below to acknowledge the date you are signing/submitting this form.
Should be Empty: