Lifeline Customer Enrollment
Consent Form

"*" indicates required fields

Step 1 of 3

Information of Qualifying Person

Please provide the information of the individual who qualified for Lifeline as it was entered at the FCC’s Qualify for Lifeline website to determine eligibility. This may be different than United & Turtle Mountain Communications’ account holder.

Please read the following statements, initial by each certification, and sign below.

By signing this form, I acknowledge and give my affirmative consent that I want to participate in the Lifeline Program through United & Turtle Mountain Communications and that I understand and certify that: