BCW Affiliate Program

Personal Information

First Name *

Last Name *

Company/Organization (if applicable)

Phone *

Email *

Street Address

City

State

Country

Postal Code

Social Security Number

Business EIN

Preferred Payment Method *

Direct Deposit

Mailed Check

Bank Name *

Routing Number *

Account Number *

How do you plan to promote BCW Agency services? (check all that apply) *

Upload a Photo of yourself

Payments will be issued monthly after verification of completed sign-ups.
I understand that fraudulent or unethical practices will result in removal from the program.

Signature *

Date *

Social Media Handle