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Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@gmail.com
City & State Where You Live*

If address is a apartment put apartment #

CityState

Zip Code
Do you currently have health insurance ?*

No I do not have health insuranceYes I have health insurance thru my jobYes I have MedicaidYes I have MedicareYes I have AmbetterYes I have BlueCross BlueShieldYes I have CignaYes I have UnitedHealthcareYes I have HumanaYes I have OscarYes I have AetnaYes I have health insurance but not sure the company name I have it with
Which shift would best fit your schedule ?*

7am - 3:00pm3:00 - 11:00pmWeekends only Saturday and SundayI want to work a flexible schedule that I choose the days and hours
Are you open to work weekends if we ever need you to ?*

Yes I'm open to working weekendsNo I can't work weekendsI may be available to work some weekendsI work my job on weekends so I'm not available to work weekends
Do you currently work a job ?*

Yes I currently work full-timeYes I currently work part-timeYes I work for companies DoorDash, UBER, Lyft to earn some extra incomeI don't have a job but I do various gigs to earn cash to keep my bills paidNo I am not currently employed with any company
Have you ever worked any type of Work From Home job before ?*

Yea I have worked from home beforeNo I haven't worked from home before
If you’re hired do you have a quiet area in your home where you can work to answer and return calls with little to no background noise ?*

Yes I do have a quiet area in my homeNo I don't have a quiet area in my homeNo I don't but I'm willing to work on creating a quiet space in my home to talk to customers
Do you have any family or friends who may also be looking for a job working from home ? If so please list all their names and phone numbers below or just type NONE.
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