Affiliate Information Form

Click the print icon below to print these pages.

Payee Name: ___________________________________
Enter the name exactly as it should appear on the check.

Preferred Payment Method (PayPal or Check): _________

If PayPal, PayPal Email Address: ________________

Address Line 1: __________________________________

Address Line 2: __________________________________

City: __________________________________________

State, Province or Region: ________________________

ZIP or Postal Code: ______________________________

Country: ______________________________________

Phone Number: _________________________________

Primary Email Address: ___________________________

Is Primary Contact same as Payee? (circle one)  Yes / No

If No, Contact Name: _________________________

Contact Email: ______________________________

Contact Phone Number: ______________________

Contact Email Address: _______________________

Your Website Profile:

What is the URL of your primary Website?:


What is your primary method of generating referrals to Marketing Rebel?:



Your Payee Tax Information

Download, complete, and send us (along with this form) the approriate US IRS tax form.
If you are a US resident, that’s a W-9, which you can find here.
if you are not a US resident, that’s a W-8, which you can find here.

By my signature below, I certify that to the best of my knowledge the statements herein are
true, complete and accurate.  I am aware that any false, fictitious, or fraudulent statements or
claims may subject me to criminal or civil penalties.


Name (print): _________________________________

Title (print): _______________________________

Signature: ____________________________________

Date: _______________________________________

Please scan & email completed and signed pages to: affiliates@marketingrebel.com .

Or fax to:  1-415-744-1864.

Or snail mail to:

Affiliate Payee Information
Marketing Rebel LLC
561 Keystone Ave, #282
Reno, NV  89503

The testimonials and case studies on this website are, to the best of our ability to determine, all true and accurate. They were provided willingly, without any compensation offered in return. 

These testimonials and case studies do not represent typical or average results. Most customers do not contact us or offer share their results, nor are they required or expected to do so. Therefore, we have no way to determine what typical or average results have been. 

Many people do not implement anything we show or teach them. We can't make anyone follow our advice, and we obviously can't promise that our advice, as interpreted and implemented by everyone, is going to achieve for everyone the kinds of results it's helped the folks on this website achieve. 

The income statements and examples on this website are not intended to represent or guarantee that everyone will achieve the same results. Each individual's success will be determined by his or her desire, dedication, marketing background, product, effort and motivation to work and follow recommendations. There is no guarantee you will duplicate the results stated here. You recognize any business endeavor has inherent risk for loss of capital.