Become an RxLINCS Enrollment Counselor

Follow these steps to complete an online application for the LINCS program:

1.  Fill out your contact information and tell us about your interests. Read the agreement at the end of the volunteer information page and provide your electronic signature by clicking "continue".

2.  List three people as references who know you well and can attest to your character, skills and dependability.

* required information    Volunteer Information First Name:* Last Name:* Birth Date: (mm/dd/yyyy) Address Line 1:* Address Line 2: City:* State:* -- please make a selection --AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaF.S. MicronesiaFloridaGeorgiaGuam HawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingNot in USA ZIP/Postal Code:* Phone:* Business Phone: Email:* How did you hear about us?: -- please make a selection --AARP LetterFriend/RelativeMediaEmployerInternetOther Are you currently employed?: Yes No Company Name: Job Title: Dates of Employment - Start Date: (mm/dd/yyyy) Dates of Employment - End Date: (mm/dd/yyyy) Highest Education Level: -- please make a selection -- Elementary Secondary High School Associate Degree Undergraduate Post-Graduate Volunteer Interests, Experience and Resources Please describe any special training, skills, hobbies: Please describe if you belong to any groups or clubs, or have any significant organizational memberships: Please describe your prior volunteer experience (include organization names and dates of service): What do you want to gain from this volunteer experience?: Are you fluent in any other languages?: Arabic Cantonese French Haitian/Creole Hindi Italian Korean Mandarin Polish Russian Spanish Yiddish Other If "other", which language(s)?: Have you ever been convicted of any criminal offense by a civilian court or by military authorities (excl. traffic violations)?:* Yes No If yes, are you currently on probation or parole?: Yes No   Please read the following carefully before continuing this application: You will be required to complete a training program before you can begin volunteer assignment. Volunteers will be expected to make a commitment of one shift a week for a minimum of one year. By clicking "Continue", I certify that all of the information provided in this application is correct. I understand that information contained on my application may be verified by Medicare Rights Center.