Lifeline Program Customer Enrollment Form

Lifeline Program Customer Enrollment Form
By signing this form, I give my affirmative consent that I want to participate in the Lifeline Program through Randolph Communications and that I understand and certify that they have the right to enroll/or transfer the benefit over to my Randolph Communications account.
Electronic Signature:

By typing your name below, you agree that this is an electronic signature.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 Digits of Social Security*
Date of birth*
mm/dd/yy
Email*
example@example.com
Application ID
Did you qualify through a dependent?*

YesNo
If you selected Yes:
BQP Name

First NameLast Name
BQP Date of birth
mm/dd/yy
BQP Last 4 Digits of Social Security
Signature with mouse/finger/stylus:*
Date*

MonthDayYear
Date
Should be Empty: