SPONSOR SUBMISSION | National Drug Card / FluffyRx Agent Agreement Terms

National Drug Card / FluffyRx
Agent Agreement
Sponsored Affiliates, Please Note:

For those who have been referred to our program by a current National Drug Card affiliate, please indicate affiliate ID below.
Sponsors Affiliate ID# (If Applicable)
If you do not have a sponsor, leave field blank. Fill in only if you were referred by another agent.
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.
Program Type*

National Drug CardFluffyRxNational Drug Card & FluffyRx
Affiliate Type*

IndividualPharmacy Industy / PharmacistDigital Marketer / BloggerNon-Profit OrganizationSole 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: