BWELL PUBLIC SERVICE FORM

Be Whole. Be Healthy. Be Well (770)940-0303

Lifeline & Affordable Healthcare

PHONE GIVE AWAY TALK TEXT AND DATA COME ON YOUR SMART PHONE!!!!

To receive your Benefit, you must have

Government Assistance SNAP (Food Stamps) Or MEDICAID, SSI, Veterans Pension and survivors benefit program, Section 8, Low

RECEIVE YOUR PHONE TODAY!!!

COMPLETE THE QUESTIONNAIRE BELOW, THEN CALL TO RECEIVE YOUR PHONE @ (770)940-0303

Free Phones & Affordable Healthcare Pre-Qualification Form

YOUR SMART PHONE COMES WITH TALK, TEXT AND DATA

The info provided must be the exact info on your ID. You must write clearly and legibly and fill in all information. Any information missing ON this FORM will result in you not qualifying.

DO YOU WORK AND NEED AFFORDABLE HEALTHCARE INSURANCE ?

YesNo

Full Name/Nombre completo*

First NameLast Name

Middle Name/Segundo nombre

Suffix/Sufijo

Date of Birth/Fecha de nacimiento*

Date

Social Security Number/Número de seguro social *

Benefit Type

Supplemental Nutrition Assistance Program (SNAP) Programa de asistencia nutricional suplementariaMedicaid/Seguro de enfermedadFederal Public Housing Assistance/Section 8/Asistencia Federal para Vivienda Pública/Sección 8Veterans and Survivors Pension/Pensión para veteranos y sobrevivientes

Email address/Dirección de correo electrónico *

example@example.com

Residence Address (No P.O. Boxes & must be your principal address)

Dirección de residencia (no se admiten apartados postales y debe ser su dirección principal)

Contact telephone number/Número de teléfono de contacto

Address/ Direccion *

Apt #City

StateZipcode

My Residential address is/Mi dirección residencial es

Temporary/TemporariaPermanent/Permanente

What is the best way to reach you?/¿Cuál es la mejor manera de llegar a usted?

Email/Correo electrónicoPhone/TeléfonoText Message/Mensaje de textoMail/Correo

Phone Number/Número de teléfono *

The Last 4 digits of your social security number *

How Did you hear about us? Who Referred You? *

Todays Date

Date

Your Phone or Tablet will be activated and handed over to you in the order your FORM is received. ACTIVATION TAKES 5 MIN PROVIDED YOUR INFO IS CLEAR, LEGIBLE AND CORRECT.

If you have to leave for any reason before your phone ACTIVATION leave the information FORM with your phone rep and your phone or will be activated and available for pick up or delivery by calling

(770) 940-0303 OR EMAIL BWell.mojemuyiwa@gmail.com