Community Resource Advocate Registry (ver2)

After you watch the 1 minute video above, complete the registration form below.

~This is the Outreach Advocate Registry

~We Authorize You To Register clients needing services and assistance.

Outreach Advocates do a great service to everyone they assist with their immediate and ongoing matters.

You make a big difference helping people with these essential services.

Your Company/Organization Name

Identity Information

1. First Name *

2. Last Name

3. Date of birth *

4. Social Security Number *

Contact Information

5. Phone *

6. Email *

7. Address (Include Apartment #)

8. City

9. State

11. Postal code

Lifeline/AHIP Experience

~Have you worked with a lifeline company or held a professional license and had your AHIP certification before?

12. Lifeline/MA Experience

Take A Selfie for Your Badge Picture

11. Badge Picture

Badge Picture

Proof of Identity Documents

~Snap a pic of your ID and SScard and submit it in the area below.

~Be sure to get all 4 sides and all 4 corners.

12. Driver License/State ID

Photo ID

Authorization

14. *Authorization: By signing below, you authorize: (a) backgroundchecks.com (“BGC”) to request information about you from any public or private information source; (b) anyone to provide information about you to BGC; (c) BGC to provide our agency and its client, one or more reports based on that information; and (d) us to share those reports with others for legitimate business purposes related to your employment. BGC may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources. You acknowledge that a fax, image, or copy of this authorization is as valid as the original. You make this authorization to be valid for as long as you are an applicant or employee with us. The Consumer Financial Protection Bureau’s “Summary of Your Rights under the Fair Credit Reporting Act” is attached to this authorization. If you are a New York applicant, a copy of New York’s law on the use of criminal records is attached. By signing below, you acknowledge receipt of these documents.

Clear

15. Supervisor or Agent's Name That Referred You to us or the Agency you work for?