National Field Enrollment Application

Thank you for your interest in our Bankers Life Social Media program! You'll be receiving additional information and next steps about the program following this survey. Please note that this second survey acts as an application to the program and will initiate an invitation to our 250 available seats.

Help us understand your interest in social marketing by completing the survey below.

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1. First Name: (Required.)

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2. Last Name: (Required.)

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3. Agent Number: (Required.)

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4. Branch Office Location (BSO + State): (Required.)

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5. Bankers Life Email Address: (Required.)

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6. Contract Date:

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7. Do you currently use social networking sites? (Required.)

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8. Which of the following social networking websites do you currently have an account with (Check all that apply): (Required.)

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9. Roughly, how long have you been using social networking sites? (Required.)

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10. In a typical week, how likely are you to use social networking websites? (Required.)

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11. In a typical week, which of the following social networking websites do you use most often? (rank) (Required.)

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12. On average, about how much time do you spend each hour using social networking websites? (Required.)

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13. In what ways do you regularly use online social networking communities? (check all that apply) (Required.)

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14. About how many "friends" do you currently have on social networking websites? (Required.)

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15. About how many of your "friends" on social networking websites have you met in person? (Required.)

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16. In order of priority, 1 being highest and 3 being lowest, which devices do you most often use?

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