Clone of WG512 Lifeline Program

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Section 1: Personal Information

Full Name (First, Middle Initial, Last)

Please enter your best contact number

Please enter your best contact email

Current city, state of residence, and zip code.

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Section 1: Other Information* This field is required.

Do you have reliable transportation?

Are you available for in-person outreach (events, property visits)?

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Section 2: Work Background* This field is required.

Physical Address (e.g., 1234 Main Street, Here, Texas 12345)

Please Enter Your Email

Last Four Digits of SSN

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Market Area* This field is required.What city or town will you be working?

Provide the city or town you'll be working in.

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Briefly explain why you’d be a good fit for this position.* This field is required.Mention any outreach, communication, or community experience you’ve had.

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Section 4: Document Uploads (Optional)Upload any supporting documents (optional):

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

Examples: résumé, certifications, or marketing samples.

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Section 5: Terms and Confirmation* This field is required.Acknowledgment | Checkbox field (Required)

I understand that this role is independent and commission-based, paying between $25-50 per each successful health coverage application.

I will represent WG512 professionally, with honesty, integrity, and respect for community members.

I agree to follow WG512’s outreach protocols and reporting guidelines.

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Electronic Signature (Required)* This field is required.Signature field