<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next Session("FP_OldCodePage") = Session.CodePage Session("FP_OldLCID") = Session.LCID Session.CodePage = 1252 Err.Clear strErrorUrl = "" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("EnrollerLogin_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "Results", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(29) Dim arFormDBFields0(29) Dim arFormValues0(29) arFormFields0(0) = "Falcon" arFormDBFields0(0) = "Falcon" arFormValues0(0) = Request("Falcon") arFormFields0(1) = "CommonCensus" arFormDBFields0(1) = "CommonCensus" arFormValues0(1) = Request("CommonCensus") arFormFields0(2) = "SSNTID" arFormDBFields0(2) = "SSNTID" arFormValues0(2) = Request("SSNTID") arFormFields0(3) = "BusinessExtention" arFormDBFields0(3) = "BusinessExtention" arFormValues0(3) = Request("BusinessExtention") arFormFields0(4) = "Address2" arFormDBFields0(4) = "Address2" arFormValues0(4) = Request("Address2") arFormFields0(5) = "CellPhone" arFormDBFields0(5) = "CellPhone" arFormValues0(5) = Request("CellPhone") arFormFields0(6) = "HomePhone" arFormDBFields0(6) = "HomePhone" arFormValues0(6) = Request("HomePhone") arFormFields0(7) = "TermsAgreement" arFormDBFields0(7) = "TermsAgreement1" arFormValues0(7) = Request("TermsAgreement") arFormFields0(8) = "OtherLanguage" arFormDBFields0(8) = "OtherLanguage" arFormValues0(8) = Request("OtherLanguage") arFormFields0(9) = "Trustmark" arFormDBFields0(9) = "Trustmark" arFormValues0(9) = Request("Trustmark") arFormFields0(10) = "StateLicensed" arFormDBFields0(10) = "StateLicensed" arFormValues0(10) = Request("StateLicensed") arFormFields0(11) = "HomeState" arFormDBFields0(11) = "HomeState" arFormValues0(11) = Request("HomeState") arFormFields0(12) = "OnlineSoftware" arFormDBFields0(12) = "OnlineSoftware" arFormValues0(12) = Request("OnlineSoftware") arFormFields0(13) = "Plane" arFormDBFields0(13) = "Plane" arFormValues0(13) = Request("Plane") arFormFields0(14) = "City" arFormDBFields0(14) = "City" arFormValues0(14) = Request("City") arFormFields0(15) = "Email" arFormDBFields0(15) = "Email" arFormValues0(15) = Request("Email") arFormFields0(16) = "Spanish" arFormDBFields0(16) = "Spanish" arFormValues0(16) = Request("Spanish") arFormFields0(17) = "OnlineSystemUsed" arFormDBFields0(17) = "OnlineSystemUsed1" arFormValues0(17) = Request("OnlineSystemUsed") arFormFields0(18) = "English" arFormDBFields0(18) = "English" arFormValues0(18) = Request("English") arFormFields0(19) = "BM" arFormDBFields0(19) = "BM" arFormValues0(19) = Request("BM") arFormFields0(20) = "FirstName" arFormDBFields0(20) = "FirstName" arFormValues0(20) = Request("FirstName") arFormFields0(21) = "Zip" arFormDBFields0(21) = "Zip" arFormValues0(21) = Request("Zip") arFormFields0(22) = "MI" arFormDBFields0(22) = "MI" arFormValues0(22) = Request("MI") arFormFields0(23) = "LastName" arFormDBFields0(23) = "LastName" arFormValues0(23) = Request("LastName") arFormFields0(24) = "OtherSoftware" arFormDBFields0(24) = "OtherSoftware" arFormValues0(24) = Request("OtherSoftware") arFormFields0(25) = "ING" arFormDBFields0(25) = "ING" arFormValues0(25) = Request("ING") arFormFields0(26) = "Address" arFormDBFields0(26) = "Address" arFormValues0(26) = Request("Address") arFormFields0(27) = "State" arFormDBFields0(27) = "State" arFormValues0(27) = Request("State") arFormFields0(28) = "BusinessPhone" arFormDBFields0(28) = "BusinessPhone" arFormValues0(28) = Request("BusinessPhone") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" End If If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If FP_SaveFieldToDB fp_rs, Now, "Timestamp" If Request.ServerVariables("REMOTE_USER") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"), "User_name" End If fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close Session("FP_SavedFields")=arFormFields0 Session("FP_SavedValues")=arFormValues0 Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") Response.Redirect "enrollerty.asp" End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> BPB - Enroller Submission Page

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Enrollment Counselor - Sign-Up

Enter your information in the fields below and you will be entered into our
Enrollment Counselor database for future consideration for on-site enrollments.  
You may update your contact and professional data as often as you need. 

We must have a copy of your current state license(s) on file for consideration.
Mail or Fax your State License Certificate(s) to our office to help speed up processing time. Address and fax number can be found at the bottom of this page.
Personal Information:
 		  
*First Name :      Middle Initial:
*Last Name: 
*SSN/Tax ID Number:

Home State:

Address: City:
State: Zip Code:

Home Phone:
Business Phone: Extension:
Cell Phone:
*Email Address:

  
Fluent Conversational Languages: English:

State(s)  Licensed:
Hold the "CTRL" 
Key to select more than one state.
Spanish:

Other:

 
Enrollment
Software
Experience:
UnumProvident Plane Software Common Census - ND Enroller
ING Enrollment Software Falcon Technologies Enrollment Software
Boston Mutual Enrollment Software Online Enrollment Systems
Trustmark Enrollment Software Please enter Online System used:
Other Systems
 

 
 By typing “Yes” in the box below, you agree to the following Terms and Conditions:

By entering  your personal and professional information, your data will become part of a database of enrollment 
counselors who are seeking temporary employment with BearPaw Inc.  This information will be kept confidential 
in our files.  Although BearPaw, Inc. is an equal opportunity employer, submission of your information for 
Enrollment Counselor does not guarantee employment with the company.

Please type "Yes" in the box if you agree to these Terms and Conditions: 


Corporate Office
3819 Corrales Road
Corrales, New Mexico 87048
888-880-2327-Toll Free
505-898-5867-Local Phone
505-898-5962-Fax