Lifeline Representative Application

Lifeline Representative Application

Welcome! Please fill out the information below to the best of your ability. If you have any questions please contact the person who referred you to this position.
Status

New
Referral Name*
Please type the name of the person who told you about the job, or, if found from a website like Craigslist AND you have not spoken to anyone choose 'Online'.
What lifeline campaign are you interested in?*

Access (CA Only)IM Telecom (Select NLAD Markets, No CA)Safelink (CA Only)TruConnect (CA + NLAD + PR)
Legal Full Name (EXACTLY as shown on Driver's License or ID Card)*

First NameMiddle NameLast Name(s)
Phone Number (Numbers only, no special characters)
Full Phone # including area code
Email*
example@example.com
Date of Birth*

MonthDayYear
Please enter correct DOB on DL/ID.
Social Security Number/TIN Number*
🔒 Your privacy is important to us. We use your Social Security Number solely for verifying your identity. Rest assured, we never sell your data. Your information will be kept secure and confidential in compliance with all relevant privacy laws. 🔒
Current Physical Address (NO P.O. Boxes)*

Full Physical Street Address (NO PO BOXES)

Apt/Ste/Bldg # (if any)

CityState

Zip CodeCountry
Shirt Size*
Please choose your shirt size.
RAD ID Application Link

Click to Apply for RAD ID Here
(↑ Click to Apply for RAD ID above ↑ if you do not have one ) RAD ID Number*
Must have all 9 characters (both letters AND numbers)
FRONT of Drivers License/ID (See example below)*

Only U.S.-Issued Driver's License, ID card, Passport Card, Passport, Permanent Resident Card, or Military ID will be accepted. MUST BE UNEXPIRED.
Cancelof
BACK of Drivers License/ID (See example below)*

Only U.S.-Issued Driver's License, ID card, Passport Card, Passport, Permanent Resident Card, or Military ID will be accepted. MUST BE UNEXPIRED.
Cancelof
HEADSHOT ONLY (See Example Below)*

*****Upload a current front-facing picture with a clean background to use as your professional badge photo. ABSOLUTELY NO snap chat filters, hats, ball caps, sunglasses, or shirtless images. MUST BE CLEAR AND NOT BLURRY.
Cancelof
HEADSHOT HOLDING DL/ID (See example below)*

*****Upload a current front-facing picture with a clean background of you holding your Driver's License or ID. MUST BE CLEAR AND NOT BLURRY. This is to prevent fraud and keep your information safe.
Cancelof
Do you have lifeline experience? (Experience not required)*

YesNo
If yes, which companies have you worked for?
Can you pass a background check?*

YesNoMaybe
If "yes", please leave blank. If answered "no", or "maybe", please explain below.
If you reside in California, please note: California’s Fair Chance Act generally does not apply to employers with fewer than five employees. These questions are asked because we are currently operating under that threshold; however, your response will not automatically disqualify you, and we will assess this information in compliance with applicable laws.
Do you have reliable transportation?*

YesNo
Do you have a tablet/phone with at least a 5.0mp camera and a data connection (not wi-fi only)?*

YesNo
Questions, comments, concerns? Tell us about yourself!
Not required.
Do you understand and accept that this position is for a 1099-CONTRACTOR and entering signing this application or any future documents does not constitute an employee-employer relationship between you and the Company?*

Yes! I understand and accept that I am a 1099 contractor and not an employee.No! I don't agree. (Your application will be discarded immediately)
By submitting this application you agree to provide your information for a potential 1099 contract with Lifeline Free Government Cell Phone Program. You understand that if you agree to sign a contract you will be sent your fee through direct deposit on a weekly cadence. You agree that you are not an employee and therefore cannot collect/receive any type of benefits, extra compensation, or reimbursements of any type.*

I agree! I want a contract!Disagree! (Application will be discarded and you will not move forward.)
Should be Empty: