Defy Master Agent Application Form

Please complete the form below to apply for a position with us.

Not a business but want to become a Lifeline Agent?

First & Last Name

Phone #

Email

What is your registered business name?

What is your business address and office location?

Do you have a valid business license or registration? (Please upload or provide documentation.)

Do you carry business insurance? If yes, what type and coverage amount?

How long have you been in business?

How many employees or contractors do you currently have?

Do you have a dedicated sales or customer service team?

Yes No

What geographic areas do you currently serve?

Do you have physical retail locations, online presence, or both?

Retail Locations Online Presence Both

Do you have experience selling telecom or wireless products/services?

Yes No

What industry are you currently operating in?

What products or services do you currently market or sell?

Who is your target customer base? (e.g., low-income households, travelers, remote workers)

Do you currently participate in any government assistance programs (e.g., Lifeline, ACP)?

What is your monthly sales volume or average customer acquisition rate?

What is your projected sales target if approved as a Defy Mobile Master Agent?

What marketing channels do you use? (e.g., social media, email, in-person outreach)

Do you have a CRM or system for tracking leads and activations?

Yes No

How do you plan to promote Defy Mobile’s Lifeline and Wi-Fi services?

Are you familiar with FCC Lifeline program rules and compliance requirements?

Yes No

Have you ever been disqualified or penalized from participating in any government telecom programs?

Yes No

Can you commit to ethical sales practices and accurate customer representation?

Yes No