Affiliate Information Form
Please print and complete this page.
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: __________________________________
State, Province or Region: ________________________
ZIP or Postal Code: ______________________________
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 appropriate 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): _______________________________
Please scan & email completed and signed pages to: firstname.lastname@example.org .
Or snail mail to:
Affiliate Payee Information
Marketing Rebel LLC
561 Keystone Ave, #282
Reno, NV 89503