Affiliate Application

First Name:

Last Name:

Date of Birth:

Business Name:

Type of Subscripcion:

Individual Group

Initial Payment

$99.99 ($99 Per User Up To 9 Users) $999.99 (Groups More Than 9 Employees)

Number Of Employees Taking Coverage

Product Interest:

Web Development Payroll Business Financing S.E.O Credit Repair Insurance Other

Email

Address:

City:

State:

Business Phone :

Alternate Phone:

Website (URL)

Business Description:

Year Established:

I have read and agree to the terms of service of N.B.B.A Affiliate Agreement

Automatic Bank Draft Authorization Form

Printed Customer’s Name(s) as they appear on Account Statement

Billing Street Address:

City:

State:

Zip Code:

Bank Name:

Name(s) Listed on Bank Account:

Phone Number:

Account Number:

Routing Number:

Select Account Type:

Checking Savings

Direct Bill Form

All invoices are mailed on the 15th of the month and payment is due by the 25th of each month.

First Name:

Last Name:

Email

Phone :

Address:

City:

State:

Zip Code:

Agent Info:

First Name:

Last Name:

Phone :

Instructions for applicants:

W-9 Form

National Business Benefit Alliance

The National Business Benefit Alliance is an organization dedicated to helping find solutions to the challenges that face Small Business Owners today. We have committed ourselves to the development of a unique benefit package that allows today’s entrepreneurs to access customized services that meet their individual needs.

5115 S Lakeland Dr Suite 1, Lakeland, FL, 33801
(888) 952-6247
info@businessbenfitalliance.com

Affiliate Application

Instructions for applicants:

National Business Benefit Alliance

Follow Us