Affiliate Information Form

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.

I ACCEPT EXCLUSIVE LIABILITY FOR ALL PAYROLL TAXES AND CONTRIBUTIONS
IMPOSED BY FEDERAL OR STATE LAWS.

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