Full Name
*
First Name
Last Name
Which Campaign are you interested in?
*
StandUp Wireless
Gen Mobile
Assurance Wireless
TruConnect
Spectrum
Enter you RAD ID ( If you don't have, apply www.usac.org/lifeline/rad )
*
What is your Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your Shipping Address for Devices?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Email
*
example@example.com
Can you pass a Criminal Background Check?
*
Yes
No
Maybe
Have you every plead Guilty or No Contest to a felony within the past 7 years?
*
Yes
No
If answered NO, leave blank. If YES to previous question, please explain.
**Picture of Valid ID** Upload a Picture of your Valid ID. Please make sure both your face and the ID are clear and fully in the picture and the ID is legible.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Headshot Holding ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Headshot Standing against Plain White Wall
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I hereby declare that the details furnished are true and correct to the best of my knowledge and belief.
*
Field Manager
*
Internal
Tammy
Krystal W
Patrick H
Brian L
Victor W.
Brian C
Agent you were referred by.
Submit
Should be Empty: