Referral Partner Application

First Name *

Last Name *

Company

Street Address 1 *

Street Address 2

City *

State / Province *

Postal Code *

Country *

Email *

Phone *

Facebook link

Commissions Payable To: *

I understand that I must have a PayPal Business account in order to receive your commission payout.

PayPalEmailAddress *

Who referred you to our partner program? *

What is your profession? *

What is your website URL? *

How many active contacts are on your email list? *

How do you plan to promote BrainTime? *

One-on-one with your clients

Promotional emails?

Zoom or Facebook Interview

Other

If you clicked "Other", let us know here:

Would you like to be notified when your referral makes a purchase? *

I have read and agree to all terms of the BrainTime Referral Partner Agreement*

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