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 Select
Online/Other
Ronald Alexandre
Angel Benitez
Beatrice Caballero
Brenda Molina Roman
Caribbean Marketing Group
Dave Cerrillo
Elpidio Ventura
Enrique Martinez
Epic Pro
Eric Gragg
Faro Alier
Gladys Jokela
James Kirkwood
Jarae Frink
Jared Jones
Jessica Hogan
John Bui
John Burrola
Kevin Vazquez
Larry King
Luis Gonzalez
Omega Resource
Rafael Salazar
Reliable Marketing
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)
Excess (CA + 48 states)
Prosper Wireless (CA Only)
StandUp (NLAD Only)
TruConnect (PR Only)
Legal Full Name (EXACTLY as shown on Driver's License or ID Card)
*
First Name
Middle Name
Last Name(s)
Phone Number (Numbers Only, No Special Characters)
*
Full Phone # including area code
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Please enter correct DOB on DL/ID.
Current Physical Address (NO P.O. Boxes)
*
Full Physical Street Address (NO PO BOXES)
Apt/Ste/Bldg # (if any)
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Shirt Size
*
Please Select
S
M
L
XL
2XL
3XL
4XL
5XL
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)
Photo of Drivers License/ID (See example below)
*
UPLOAD VALID DL/ID
Drag and drop files here
Choose a file
Only U.S.-Issued Driver's License, ID card, Passport Card, Passport, Permanent Resident Card, or Military ID will be accepted. MUST BE UNEXPIRED.
Cancel
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HEADSHOT ONLY (See Example Below)
*
UPLOAD HEADSHOT
Drag and drop files here
Choose a file
*****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.
Cancel
of
HEADSHOT HOLDING DL/ID
*
UPLOAD HEADSHOT
Drag and drop files here
Choose a file
*****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.
Cancel
of
Do you have lifeline experience? (Experience not required)
*
Yes
No
If yes, which companies have you worked for?
Can you pass a background check?
*
Yes
No
Maybe
If "yes", please leave blank. If answered "no", or "maybe", please explain below.
Please answer to the best of your ability. False or misleading information is grounds for an automatic denial and/or termination.
Do you have reliable transportation?
*
Yes
No
Do you have a tablet/phone with at least a 5.0mp camera and a data connection (not wi-fi only)?
*
Yes
No
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)
Questions, comments, concerns? Tell us about yourself!
Not required.
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.)
Continue to Background Check Authorization
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