MNS Agent Application
Office Code:
Please Select
MNS
CC (ALT-02)
ALF
Essence
JUAF
JJ
VLAD
LOREM
Referral/Manager Name:
*
Name
*
First Name
Middle Name
Last Name
Suffix
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
 -
Month
 -
Day
Year
Date
Full SSN/ITIN
*
RAD ID
*
Register here: https://LifelineRad.org
Address
*
Street Address
Street Address 2 (APT, UNIT)
City
State / Province
Postal / Zip Code
Background Check: When did you move to this address?
*
 -
Month
 -
Day
Year
Date
Â
YES
NO
UNSURE
Can you pass a background check?
Do you have your own car?
Do you have cell phone service with data?
Do you have experience in the Lifeline industry?
If you have experience, which company did you previously work for?
Which program would you like to join?
*
Gen
Tru-Connect
Entouch
COVID Testing
Back
Next
🚨READ CAREFULLY: Pics below must be clear, no blur/no hats or hoodies/headphones/glasses. *ALL 4 CORNERS* of the ID need to be visible. Do you fully understand?
*
Please Select
Yes
ID Only Picture
*
Browse Files
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of
Face Headshot Pic
*
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Choose a file
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of
Pic of Holding ID Next to Face
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I understand I am responsible for holding the inventory and must activate devices within 30 days otherwise will be charged $70 per device. Signature:
*
Submit
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