Distributor Application

Distributor Application
Full Name:

First NameLast Name
Company Name:
Anticipated Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
RAD ID (if applicable):
Upload screenshot of USAC Email with RAD ID.

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Can't find your RAD ID? Click on the link and select "Forgot Rep ID".

https://lifelinerad.org/rad/#/Landing
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What experience do you have in Lifeline or Sales?
Are you willing to submit to a background check?
Were you referred by anyone? If yes, please list their name:
Please upload background check results:

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Should be Empty: