Affiliate Registration
Section 1: Personal & Contact Information
Full Legal Name
Business Name (if applicable)
Phone Number
Email Address
Mailing Address
Entity Type
Individual
LLC
Corporation
Other
Referred By
Present Profession
Section 2: Affiliate Role & Expectations
Desired Role
States to Refer Business
How will you refer clients? (social media, events, direct network, etc.)
Have you referred clients before? If yes, please explain
Licenses Held (if any)
Why are you a great fit?
Section 3: Compliance Acknowledgment
I may not misrepresent financial products or my role.
I will not collect sensitive financial documents or promise loan approvals.
I agree to comply with all privacy and regulatory requirements.
Print Name
Date
Signature (type full name)
Submit
