WG512 Programs | Agent Application

1
Which Role Are You Applying For?* This field is required.Lifeline Agents distribute free mobile devices with service to eligible customers. Field Collectors engage registered voters to collect petition signatures. Testing Collectors play a critical role in protecting public health by collecting and processing biological specimens accurately and compassionately. An Independent Business Owner (IBO) builds and manages a team of agents, while also having the option to work within projects independently.
Please Select
Lifeline Agent
Field Collectors
Testing Collectors
Independent Business Owner
Please choose one (1) or more options.
2
Personal Information* This field is required.Enter your full legal name (first, middle if applicable, last).
First Name
Middle Name
Last Name
Suffix
3
Basic Information * This field is required.Provide the requested information below.
Physical Address (e.g., 1234 Main Street, Here, Texas 12345)
Please Enter Your Email
4
Best Contact Number* This field is required.Enter the best phone number to reach you.
Format: (###) 123-4567
5
Logistics* This field is required.Provide the requested payroll information below.
Please Select
Please Select
Direct Deposit/ACH
Venmo
CashApp
PayPal
Chime
Zelle
Preferred Method of Payment
6
Identity Verification* This field is required.Upload one (1) form of valid, unexpired identification.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Examples of Accepted Proofs are State-Issued ID Cards, Driver's License, US Passports & Social Security Cards.
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7
RAD ID (Only for Lifeline Agents)A RAD ID (Representative Accountability Database ID) is a unique number required by the federal government for all Lifeline agents. It verifies your identity and allows you to enroll customers in the Lifeline program. If you don’t have one, please register for a RAD ID before you move onto next steps.
Please Select
Please Select
Yes
No
Do You Have a RAD ID? || Choose Yes or No.
Enter Your RAD ID (9-Digits)
8
How Did You Hear About Us?
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