Affiliate Application

Name(Required)

First Last

Phone(Required)

Email(Required)

Company Name(Required)

Would you like to receive a check or an ACH(Required)

Check

ACH

Where Should We Mail Your Check?(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is this a Checking or Savings Account?(Required)

Checking

Savings

Please enter Routing Number(Required)

Please enter Account Number(Required)

Please enter Name on the Account(Required)

Investors Kit