CHC Representative Application

To Join Our Professional Healthcare Team

Welcome: Here's a few things you need to know. We respect your privacy. We won't share your information with anyone without your permission. Also, Your responses will be confidential and will not be disclosed to anyone outside CHC.

Directions: Click the Step 1 Blue Banner and that section will open. Answer a few questions and move to the next Step. The more information you can provide will help us prepare your agreement. When Completed, Click the Hug to send us your Application information.

Thanks for your interest and participation.

Click Step 1 to begin.

Title (Mr., Ms, Dr., etc.)*

First Name*

Last Name*

Full Address*

Email*

Telephone #*

Cell #*

DOB*

Current Employment

Company*

Title*

Years Employed*

Type Of Work*

Sales Experience

Years

Type / Describe

Healthcare Experience

Years

Type / Describe

Other

Hobbies & Favorite Activities

Organizations You Belong To

Do you have an Insurance License?
(Not Required to be a CHC Rep)

Type of Computer or Tablet you use

How did you hear about CHC?

Have you ever filed for bankruptcy?
(If Yes, please describe including date)

Have you been convicted of any crime?
(If Yes, please describe including date)

Describe the reason you want to become a CHC Representative

Additional Comments or Questions

Once you've completed all the relevant fields, Click the "Sending My Application" HUG and we'll quickly get back to you.

CHC Representative Application

To Join Our Professional Healthcare Team

Thanks for your interest and participation.

Click Step 1 to begin.

Step 1 - Please Introduce Yourself

Step 2 - Please tell us a few things about yourself

Current Employment

Sales Experience

Healthcare Experience

Other

Step 3 - Additional Helpful Information

What Would You Like To Do Next?