Request a Partnership Perks Card
Please use this form to request your Partnership Perks discount card.
Enter your full shipping address as this is the address the cards will be mailed to. Please allow 5-7 days to receive your requested card(s).
First and Last Name *
Your answer
E-mail address *
Your answer
Phone number *
Your answer
Street Address *
Your answer
City, State, and Zip Code *
Your answer
Number of Cards Requested *
Your answer
How did you hear about the Partnership Perks program? *
Your answer
LIC Affiliation *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.