MightyWELL Affiliate Agreement
Zion & Planstin
Affiliate Information
Name
*
First Name
Last Name
Cell Number
*
Please enter a valid phone number.
Email
*
example@example.com
Company Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Recrutiting Affilate
Name
First Name
Last Name
Writing Number
Date
-
Month
-
Day
Year
Date
Direct Deposit ACH Authorization
Account Individual or Business Name
Bank Account SSN or Tax ID
Account Type
Checking
Savings
Bank Name
Account Number
Routing Number
Signature
Back
Next
W-9
Name
First Name
Last Name
Check appropriate box for federal tax classification.
Individual/sole proprietor or single-member LLC
C Corportation
S Corportation
Partnership
Trust/Estate
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SSN
EIN (if needed)
Signature
Signature
Date
-
Month
-
Day
Year
Date
Prior to submitting your agreement, be sure to preview and download a copy for your records and to email to providers.
*
I acknowledge
Preview your Agreement
Download
Submit
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