Leadership Services Affiliate Program

Before finalizing and submitting your application, please review it to ensure you have provided accurate information. Once you have filled out this form and reviewed it, press the "Yes" button to submit your application or the "No" button to exit.

Payee Information
Please fill out the name and address of the person or company to whom we should make checks payable. Please note that we can only accept one payee name in the box below.

Payee's name:
(Please enter ONLY the name of the person or entity to whom the check should be written)


Address Line 1:


Address Line 2:


City | State | Zip/Postal Code:
  

Phone Number:


Payee's email address:

Contact Information
Please enter the name and address of the person to whom we should address all correspondence about your participation in the Associates Program. (Leave blank if same as payee)

Contact person's name:


Address Line 1:


Address Line 2:


City | State | Zip/Postal Code:
 

Phone Number:


Contact person's email address:

Web Site Information
Enter the name and URL of the Web site you wish to link to Leadership Services, LTD.

Name of your Web site:


Home page URL of your Web site:

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