Please complete the following and submit for nomination to become an AFE InfluencerOrganization/Business Name Org/Bus. Name* Primary Contact: First Name First Name* Last Name Last Name* Email Address Email* Phone Number Area Code* Phone Number* Referred By: First Name First Name* Last Name Last Name* Note: The replicated website url is preassigned and cannot be changed. It is not active until your nomination is approved by AFE. Mailing Address (specific #, street name, Suite, etc) Street Address Street Address 2 City State Zip W-9 InformationIndividual/Organization/Company W-9 Individual/Org/Co* Company Type Please Select Individual C Corporation S Corporation Partnership Trust/Estate LLC * Tax ID/SS # Tax ID/SS#* Bank Name Bank Name* Bank Acct Type Please Select Checking Savings * Routing # Routing #* Bank Phone Number Area Code* Phone Number* Bank Address: City Bank City* Bank State* Bank Zip*Bank Account Number Bank Account Number* Date of Submission: Date Signature Signature*
This information is used solely for review of your nomination. This information cannot be accessed by the person who nominated you.
With this signature, I certify that all information provided is true, accurate and complete to the best of my knowledge:Electronic Signature: First and Last Name*