Chronic Condition Rescue Affiliate Application

Name

First NameLast Name
Email
example@example.com
Paypal Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Assistant's Name

First NameLast Name
Assistant's Phone Number

Area CodePhone Number
Assistant's Email
example@example.com
What is the URL for Shivan to register as an affiliate for your programs?
What is your promo plan? (i.e. solo email dates, newsletter highlights, social media, FB ads, etc.)*
Should be Empty: