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Agent CVS Form

    ***IMPORTANT***

    In order to participate in the CVS SilverScript Kiosk Program, during this year’s OEP, you must be contracted with SilverScript through Empower and you must have your AHIP certification up to date.

    To register with Empower and request appointment with SilverScript, CLICK HERE NOW!

    Your FULL Name (required)

    Your Phone (required)

    Your Email (required)

    Your Subject

    Please list, below, your ideal location and a few backup choices. (full addresses only)

    I understand that I must be contracted with SilverScript, through Empower Brokerage, in order to participate in the CVS Retail Opportunity

    Please list your SilverScript writing number

    By checking this box, you consent to receive text messages from Empower Brokerage and/or a licensed Empower Brokerage agent. These messages may include marketing messages (e.g., promotions, reminders) and follow-up communications related to your inquiry to the number provided, which may include the use of an autodialer. Message and data rates may apply. Message frequency varies. You can unsubscribe at any time by replying STOP or clicking the unsubscribe link.

    By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign about insurance services and other options from Empower Brokerage or a licensed agent, and I will receive phone calls and e-mails (even if that phone number is on any Do Not Call Registry or is a mobile number). If you want to opt out of receiving future e-mails from Empower Brokerage, you can do so at any time by clicking the “unsubscribe” button in our e-mail. For more details, see our Terms and Conditions and Privacy Policy.

    Standard text and data rates may apply. You can opt out of receiving text messages from Empower Brokerage at any time by replying to an Empower Brokerage text message with “unsubscribe”, “stop”, “end”, “no”, or “opt out”. If you want to opt out of receiving future e-mails from Empower Brokerage, then you can do so at any time. Please click the “unsubscribe” button in our e-mail. Empower Brokerage values your privacy and will not share your personal information with any other business or persons.