Join the Team

Representative Sign-Up

Complete this form to become an NCH representative. NCH issues your Rep ID once your W-9 is received and screening is complete.

Role

Church Recruiting Representative
Recruit churches to The War on Diabetes in the Black Church™.Commissioned Representative (physician practices and clinics)
Identify physician practices and clinics that want to license Obesity Data™.

Your Information

Full Legal Name Mobile Phone

Business Name (If Paid to a Business) (Optional) Email

Street Address City, State, ZIP

Area You Will Recruit In

Tax Information (1099)

Tax Classification

Do not enter your Social Security or tax ID number here. NCH will send you a W-9 to complete securely. NCH issues a Form 1099-NEC to any representative it pays $2,000 or more in a calendar year.

Certifications

I am not excluded from any federal health care program (OIG LEIE list), I consent to monthly screening, and I will tell NCH immediately if that changes. I will present only NCH-approved materials and will not make revenue or reimbursement projections of my own, give health, clinical or billing advice, or recommend any provider or service. I will not handle patients’ or participants’ information or contact patients, and I will not accept payment from any church, provider or practice. I am an independent contractor, not an NCH employee, and I am responsible for my own taxes.