Affiliate Request Form

Please fill out the information form below. Once you sign up, you will receive a link that you can immediately place on your web site. The information you provide will be kept confidential and will be used to ensure prompt payment of affiliate fees.


Web Site Information
Site Name:
Site URL:
Site Category:


Primary Contact Information
First Name:
Last Name:

Phone Number:
Email:

Mailing Address:
City:
State/Province:
Postal/Zip Code:
Country:


Payee Information
Same Payee as Primary Contact (If same, check box and can leave fields below blank)
Name:
Address:
City:
State/Province:
Postal/Zip Code:
Country:


Payment Information
		Send Me a Check Pay Me With Paypal
Paypal Email:
Business Classification:
Fed Tax ID (Corp.) or Social Security # (Indiv.):
I Agree with the Terms and Conditions of the MyScorecard Afffiliate Program

Affiliate Request Form

Web Site Information

Primary Contact Information

Payee Information

Payment Information