WGC-Lifeline Program Registration Form

WGC-LIFELINE REGISTRATION FORM

Customer Information

Your Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Last 4 of SSN*

Birth Date Required*

MonthDayYear

Your Contact Number*

Area CodePhone Number

Your E-Mail*

example@example.com

Qualifying Benefit for the Lifeline Program*

UPLOADS NEEDED FOR APPLICATION SUBMISSION

Government ID*

Upload a CLEAR Copy of your Current and Valid Government ID

Socical Security Card

Upload a CLEAR Copy of your Current Social Security Card

Benefits Verification Form

Upload a CLEAR Copy of your Current Benefits Award or Verification Letter

Additional Info

WGC Lifeline Device Application - Disclosure & Consent

By submitting this application, you acknowledge and agree to the following terms regarding the collection, verification, and processing of your information for the Government Lifeline Device Program:

1. Accuracy of Information

You certify that all information provided in this application, including your full name, address, date of birth, last four digits of your Social Security Number (SSN), email, and a clear copy of your Government-issued ID, is accurate and truthful.

Any incorrect, incomplete, or false information will result in automatic rejection of your application.

If your application is rejected due to errors or unclear images, you will be notified of the necessary corrections to reapply.

2. Verification & Response Time

Once submitted, your application will be reviewed to determine eligibility. Please allow up to three (3) business days for an official response; however, some applicants may receive a response sooner.

If additional information or corrections are needed, you will be contacted via phone, email, or text message.

3. Fraud Prevention & Eligibility Restrictions

The Lifeline program is strictly limited to one device per eligible household. Submitting multiple applications or providing false information to obtain multiple devices is considered fraud and may result in legal consequences and permanent disqualification from the program.

Your eligibility is determined by government guidelines, which may include participation in qualifying assistance programs or meeting income-based requirements. Approval is not guaranteed.

4. Data Privacy & Security

All personal information provided in this form is confidential and will be used solely for verifying eligibility for the Government Lifeline Device Program.

WGC follows strict data protection measures to safeguard your personal information; however, you acknowledge that WGC is not liable for any unauthorized access or data breaches beyond its control.

5. Consent to Contact & Communication

By submitting this application, you consent to being contacted via phone, email, or text message regarding:

The status of your application

Any required corrections

Important updates related to the Lifeline Device Program

By selecting the option below and submitting this form, you agree to these terms and confirm that all information provided is accurate to the best of your knowledge. I have read and agree to the above terms and conditions.

YesNo