WGC-Lifeline Benefit Registration Form
Customer Details
Full Name
*
First Name
Last Name
Date of Bith
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What Benefit would you like to qualify with?
*
Please Select
Medicaid
EBT
SSI
VA Pension
Section 8
WIC
Low Income (W-2)
Enter Last 4 of Social Security Number
*
Upload any Valid Documents for Additional Verification (W-2, Benefit letter, ect.)
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Have you received or currently have a Lifeline device? With what company and when? :
Interested in learning about Free/Discounted Home Internet options?
Yes
No
Maybe
Would you like to refer someone that also maybe interested in receiving a Free/Discounted Lifeline device?:
Rows
Full Name
Address
Contact Number
1
2
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