Lifeline Application Form

How can we reach you?

Lifeline application information

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(Why do we need this information?)

Choose Your Lifeline Service Plan

Installation Preference

Responders (What is a Responder?)

Responder #1

Responder #2

If you need assistance when filling out this application, please call our office at (204) 956-6777 or toll free in Manitoba at 1-888-722-5222.
By submitting this information, you authorize Victoria Lifeline to begin the application process and to contact you regarding this service request.