Lifeline Enrollment Agent Interest Form

Thank you for your interest in becoming an Enrollment Agent.

The Lifeline Wireless and Affordable Connectivity Programs generally provide low income households the ability to receive FREE Wireless Service! Applicants may qualify if they are receiving government benefits (like SNAP, Medicaid) or if they can show proof that their Household income meets certain guidelines.

Get Paid to give Free Minutes, Free Text, Free Data!

(COMMISSION BASED PAY ONLY-You are going to be an Independent Contractor. )

Please fill out the form below and we will get back to you with more information. Your entries will help us determine how we can work togther.

Full Name*

First NameMiddle NameLast Name

Phone Number*

Email*

Confirmation Email

How did you hear about this Service or who referred you?*

(Enter the source of Advertising or the FULL NAME of the person who told you about this program)

Are you 18 Years of age or older?*

YESNO

Do you have access to reliable transportation?*

YESNO

Do you have a SmartPhone with Internet Service?*

YESNO

Do you have a Tablet with Internet Service (iPad or Android)?*

YESNO

Do you have Wireless Internet or WiFi HotSpot?*

YESNO

Do you have a Bank Account or Financial Institution with Routing and Account numbers?*

YESNO

Lifeline/ACP Agent Experience:*

Are you currently representing a Lifeline or ACP Service Provider?*

YESNO

Name of Lifeline or ACP Service Provider(s) you are currently representing?

Name(s) of Lifeline or ACP Service Provider(s) you have represented?

(Other than what you entered above)

How do you get Inventory, Event or Marketing materials?(Check all that apply)*

MailWill Call or Pick UpDelivery by AgencyOther

How do you manage your Inventory of phones? (Please explain in detail) *

Examples: "I drop 20 phones and leave it up to the agents to tell me what they have left" “I have an inventory tracking system that shows me, by serial number, who has what phones.”; “I know how many AND exactly what phone models and IMEIs my agents have.”; “When I assign phones, my agents have to sign an Invoice that CLEARLY shows what phone models AND Serial Numbers they are receiving from me”; “I can show proof that I know EXACTLY who each device I released was assigned to.” "I give a box of phones and wait until my agents call me to get more." "I count phones with my agents weekly."

How many days are you given to activate the Inventory provided to you before they become Past Due?*

Enter Payment Terms in number of days or if you pay when delivered.

How often do you reconcile Inventory with your current Agency or Manager?*

(Weekly, Monthly, every 3 months, etc.)

How many people in your Team?*

How and Where do you currently or plan to offer Lifeline or ACP services?*

Describe your marketing strategies. Name places like churches, street events, door-to-door, swap meets, mailers, online advertising, inside an office, etc.

Number of activations per month*

City or cities and State you plan to work in?*

How and Where do you currently or plan to offer Lifeline/ACP services?*

Describe your marketing strategies. Name places like churches, street events, door-to-door, swap meets, mailers, online advertising, inside an office, etc.

Days and times you are available to work?*

When Can You Start?*

MonthDayYear

Please type any comments, suggestions, feedback or questions below:

Lifeline/ACP Enrollment Agent Interest Form