Mystery Shopper Application | Medical Mystery Shopping & Long Term Care Shopping Services

Today's Date*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Telephone*

Mobile Phone*

Email Address*

Enter Email Confirm Email

Age*

(We would like this information in order to be able to be able to determine if you will fit the client's requirements.)

Are you?*

(We need this information in order to make the required assignments.)

If "Other," please specify.*

Are you currently employed?*

(Does NOT include mystery shopping.)

Yes
No
Looking for a job

Where are you employed and/or what is your job function?*

(We will not contact your employer. )

Are you a Silver Certified Shopper?*

Yes
No

Are you a Gold Certified Shopper?*

Yes
No

Please provide your Gold Certification number.*

How many months or years have you been mystery shopping REGULARLY?*

Are you available to travel ...*

Within 25 miles
Within 50 miles
Not sure where or need more information

Do you own or have 24/7 access to ...*

(Check all that apply.)

Computer/laptop
iPad or its equivalent (Do NOT check if you only own a smart phone, no matter how large.)
Other

If "Other," please specify.*

Do you have 24/7 internet access IN your home?*

Yes
No
Sometimes / Intermittent

Is your internet access?*

Cable
DSL
WiFi
Dial-up

(Check all that apply.)

Do you currently have equipment to perform video shops?*

Yes
No

Do you have experience performing video shops?*

Yes
No

Please submit a writing sample of at least 100 words. You will not be considered without a writing sample. (This is a rolling box with plenty of room.)*

Name

This field is for validation purposes and should be left unchanged.