Covered California Enrollment Application

Covered California Certified Enrollment Counselors Application

You can make $25 per successful enrollment. Fill out the application below if you would like to be considered for the position. Sign Up Now!
Certified Enrollment Counselors are trained individuals who are available to provide in-person counseling and assistance to consumers in need of help with applying for Covered California programs. Counselors will provide assistance in culturally and linguistic appropriate manners to consumers throughout Bakersfield California. Each person will go through a full 3 day training to become certified to enroll anyone into the program. We are looking for 15 people who would like to become certified. Sign Up Today!!!
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Employment Status
Present Employer
Employer Address
Occupation
How long have you been employed?
Are you Full Time or Part Time
Availability for Covered California?
Educational History
Highest level of education achieved

High SchoolTechnical TrainingCollegeOther
Additional Information:
Please list two references that we can call. Do not list relatives.
1. Name
Phone
Relationship
2. Name
Phone
Relationship
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Covered California Certified Enrollment Counselors Application