|
Check here to indicate that you have read and agree to the terms of the GlutenSmart Affiliate Agreement. Also, you must have a PayPal account to participate in the program. |
|
Your Web Site
Information
|
|
Site Name:
|
|
|
URL
of Site:
|
|
|
Site Description and Comments:
|
|
|
Primary Contact
|
| First
Name: |
|
|
Last Name:
|
|
|
Title:
|
|
|
Contact E-mail:
|
|
|
PayPal E-mail:
|
|
|
Mailing Address
|
|
Address
1:
|
|
|
Address
2:
|
|
| City: |
|
| State: |
|
| Zip
Code: |
|
|
Country:
|
|
|
Phone:
|
|
|
Fax:
|
|
|
Pay To Address
|
|
Pay
To Name:
|
|
|
Address
1:
|
|
|
Address
2:
|
|
| City: |
|
| State: |
|
|
Zip
Code:
|
|
|
Country:
|
|
|
Phone:
|
|
|
Fax:
|
|
Important Information |
|
| What
is your business / personal tax classification?
|
| What
is your Social Security Number (individual) or Federal Tax
ID (corporation)? (If you are an individual and reside in the US, you do not have to provide your social security number at this time. If your Affiliate Fees total over $600 in a calendar year, you will need to provide your Social Security Number at that point.
|
How
did you hear about our affiliate program?
|
|
By
submitting this application you acknowledge that you have
read the GlutenSmart Affiliate Agreement and agree to be bound by its terms and conditions. Please note that this form will submit you application using your e-mail system in the background. Please feel confident that when you click the "Agree & Submit" button below that your information has been delivered to our affiliate team. We will reply to your request within 48 hours.
If you have any problems you can always fill out this page,
print and fax to us at 714.964.9120
|
