Please list the following information:

1. First and last name
2. Email Address we can contact you at
3. Phone number
4. Website(s) you will display affiliate information on (list all that apply)
5. Instagram Account
6. Facebook Page
7. Youtube Channel

What other brands are you currently an affiliate for? What brands have you been an affiliate for in the past?

How will you share my information and how often?
1. Website(s) - List all and how often
2. Email - how often do you send emails to your list?
3. Email - how often do you send emails that include affiliate marketing?
4. Facebook ads
5. Instagram ads
6. In person classes
7. Online classes, workshops or webinars
8. Other (please explain)

Have you had any issues with the FTC currently or in the past? Please explain.

Please tell us about your company!

1. Where are you located?
2. How long have you been around?
3. What's your company's mission and values?
4. What services or products do you provide?

How did you hear about our Infection Prevention & Control Course?

Have you taken our IPAC Course?
Do you know what protocols/principles we teach and do you agree with them?
Do you hold a current IPAC Certificate from us?

Why do you want to be an affiliate for our IPAC Course?