NDC3496 Brent Heurter - National Drug Card / FluffyRx Agent Agreement Terms

National Drug Card / FluffyRx
Agent Agreement
WOW Insurance Marketing Inc.
Sponsored Affiliate Form

For those who have been referred to our program by WOW Insurance Marketing Inc. Please fill out the form below to complete your signup to the National Drug Card Affiliate Program.
Name*

First NameLast Name
Year Born*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Website
Website & Mobile Apps

The information below will be used across all your marketing material. Website, Cards and Mobile Apps.
Affiliate Type*

IndividualPharmacy Industy / PharmacistDigital Marketer / BloggerSole ProprietorPartnershipAssociationCorporation
Name or Title (If Applicable)
Personal Name, Company Name, Organization or Titles can be used.
Phone Number (If Applicable)
To appear on Website and Mobile Apps
NDC Agent Agreement
Please review, print and/or download the
NDC Agent Agreement PDF linked below.
Electronic Signature*
Signing above has same bond as written signature.
Company Name (Optional)
Date*
Month/ Day / Year
By clicking the submit button, I agree to terms & conditions provided in the Agent Agreement PDF document linked above.
Should be Empty: