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
What is Your Job Description? *
Company *
Tax ID
Gender *

Male Female
Upload Photo ID

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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:

Mailing Address