Climax X LLC Affiliate Form

Climax X LLC Affiliate Form

Want to make additional Income?
First Name *
Last Name *
Phone Number *

Country Code Area Code Phone Number
Email *
example@example.com
Date of Birth

Month Day Year
Date
What is Your Job Description? *
Company *
Tax ID
Gender *

Male Female
Upload Photo ID

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Click on the appointment "Earn Additional Income". We can get your account set up with your own personal referral code and marketing materials.
Mailing Address

Please enter your mailing address
Address *

Street Address

Street Address Line 2
City *

Street Address

Street Address Line 2

City
State *

Street Address

Street Address Line 2

State
Postal Code / Zip Code *

Street Address

Street Address Line 2
Country *

Street Address

Street Address Line 2

Country
Affiliate Form
Website Information

Please enter current website information below.
Website URL *
Monthly Visitors *

0 - 3,999 4,000 - 7,999 8,000 +
Promotional Methods / Other *
Under Penalties of perjury, I certify that: *

1. The number show on this form is my CORRECT taxpayer identification number or SSN. 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Servuce (IRS) that I am Subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.
Should be Empty:

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