Name (as it appears on license)

Preferred Name

Your Email

Street/P.O. Box

City

State

Zip Code

Preferred Contact Phone Number

Cell Phone Number

Date of Birth

Requested Daily Rate

Are you willing to travel?
YesNo

If yes, please note any restrictions here:

Nearest Airport

Do you have a major credit card (not debit card) to use for travel purposes?
YesNo

Do you own a laptop?
YesNo

Do you own a portable printer?
YesNo

Are you willing to work multiple shift enrollments?
YesNo

Are you bilingual?
YesNo

If yes, what language?

ENROLLMENT BACKGROUND

Years of Enrollment Experience

Please check all that apply to your experience?
One-to-One PresentationsLaptop PresentationsCore EnrollmentsGroup PresentationsCall Center - if yes please complete the following information:

Do you enjoy call center work?
YesNo

Why?

Where have you conducted call center enrollments?
Enrollment Company Call CenterHomeOther

If other:

If provided with the necessary telephone equipment, do you have a quiet and secure place in your home where you could take enrollment calls?
YesNo

Indicate type of internet connection you have at home:
Dial-upDSLCableOther

If other, describe:

Multi-location experience:
YesNo

Multi-shift experience:
YesNo

List any enrollment companies for whom you have experience:

Core Benefits:
MedicalDentalVisionSection 125FSAHospital Indemnity

Voluntary Benefits:
Short Term DisabilityLong Term DisabilityTerm LifeAD&DWhole LifeCritical IllnessAccidentOther

Electronic Enrollment Experience:
YesNo

If yes, please list the enrollment platforms you have used

LICENSING INFORMATION