Lifeline
Enroll Subscriber
Provide the Subscriber’s Full Name
Provide the Subscriber’s Full Name
First Name
Middle Name
Last Name
Suffix
Provide the Subscriber’s Address
Provide the Subscriber’s Address
Primary Address
Apt, Unit, etc
City
State
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ZIP Code
Is the subscriber's mailing address different from their physical address?
Yes
No
Provide the Subscriber’s Telephone Information
Phone No. is optional to verify
Provide the Subscriber’s Telephone Information
Phone No. is optional to verify
Service Type
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Service Initiation Date
mm/dd/yyyy
Phone Number
(xxx) xxx-xxxx
Lifeline Tribal Benefit?
Yes
No
Subscriber Eligibility Information
Subscriber Eligibility Information
Eligible Program
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IEH Certification Date
mm/dd/yyyy
Linkup Service Date
mm/dd/yyyy
Independent Economic Household?
Yes
No
Tribal Address?
Yes
No
Temporary Address?
Yes
No
Non-Deliverable Rural Address?
Yes
No
ETC General Use
ETC General Use
Provide any additional comments or notes.
Terms & Conditions
Terms & Conditions
I accept the terms and conditions.
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