Affiliate Application - The Denali Group

AFFILIATE SIGN UP APPLICATION

Nam(Required)

Prefix First Last

Current Position/Title **(Required)

** Please tell us what role you are currently in with your primary employer. PLEASE NOTE: Denali Group will NEVER contact your Employer. This is just for our information only.

Referral Resource

How did you find out about Denali Groups Affiliate Program? (If you were referred by someone, please give us their name so we can thank them). If not referred by someone just type “NONE”.

Years of Experience(Required)

Please indicate how much experience you have in your chosen field.

Email(Required)

Enter Email Confirm Email

Please provide an email address that you will regularly check for updates from The Denali Group, Inc.

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please include address for USPS Correspondence. Please note this must be your physical street address.

Dental Industry Field/Role(Required)

Please select the area(s) of the dental industry that you are currently involved in.

EIN or SSN(Required)

Please provide your Employer Identification Number or Social Security Number for your 1099 issued at the end of the year.

What current territories or Regions do you cover (If Nationwide state so below).(Required)

Professional Organization Memberships

Please tell us what professional organizations that you are a member of.

PayPal Account(Required)

Denali Group will distribute commission through Bulk Pay via PayPal. Please include your PayPal account ID. PLEASE DO NOT INCLUDE ANY PASSWORD INFORMATION.

Social Media Presence/Use(Required)

Please tell us about what social media platforms you use professionally to attract/share with your customers about your services? Please select all that apply.

How do you plan to promote/use the Demographic Study Application?(Required)

Plesae tell us how you plan to use the service, and how Denali Group can assist in those goals.

Commission / Discount Selection(Required)

We offer two affiliate options. You may choose 20% of net collections on unique link use or a 20% discount for all of your clients. Selection of discount option will require unique coupon code. That will be provided on approval of application.

Do you have a felony conviction?(Required)

Please state yes or no. If yes, please provide high level details to be considered.

PEASE REVIEW THE ITEMS BELOW CARFULLY. IF YOU ARE IN AGREEMENT PLEASE CLICK THE BOX NEXT TO THE ITEM. FAILURE TO CHECK ANY BOX WILL PREVENT DENALI GROUP FROM APPROVING THE APPLICATION. PLEASE NOTE THAT THIS WILL BE BINDING IF YOUR APPLICATION IS APPROVED.

W-9 File Upload

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 64 MB, Max. files: 2.

Please upload completed and signed W-9 with your application. (You can email separately to support@thedenaligroup.net if you need to).

Name

This field is for validation purposes and should be left unchanged.