Centranet Lifeline Enrollment

1
Name* This field is required.
First Name
Last Name
2
Centranet Account Number* This field is required.Service must be active with Centranet before applying for the Lifeline benefit.
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email* This field is required.
example@example.com
5
Lifeline Application ID* This field is required.
6
Lifeline Application Date* This field is required.Please enter the date you applied for Lifeline
Date
Month
Day
Year
7
Do you live on Tribal lands?* This field is required.https://www.lifelinesupport.org/wp-content/uploads/documents/get-lifeline/fcc_tribal_lands_map.pdf
YESNO
8
Please select one qualifying government assistance program OR select that you qualify through your income.* This field is required.
Supplemental Nutrition Assistance Program (SNAP) (Food Stamps)
Supplemental Security Income (SSI)
Medicaid
Federal Public Housing Assistance (FPHA)
Veterans Pension or Survivors Benefit Programs
Bureau of Indian Affairs (BIA) General Assistance
Tribal Temporary Assistance for Needy Families (Tribal TANF)
Food Distribution Program on Indian Reservations (FDPIR)
Tribal Head Start
Eligibility Based on Income
9
Last Four Digits of Applicant's Social Security Number* This field is required.
10
Applicant's Date of Birth* This field is required.
Date
Month
Day
Year
11
Please review the following Lifeline Terms

https://www.centranetfiber.com/home/assistance-programs/lifeline

You will be asked to agree to these statements on the next page.
12
Agree to Lifeline Terms* This field is required.
I agree to all Lifeline Terms
13
Signature* This field is required.
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