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AFFILIATE BROKER APPLICATION
Name
*
Prefix
First
Last
Suffix
Date of Birth
*
Month
Day
Year
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone Number
*
Secondary Phone Number
Email
*
Enter Email
Confirm Email
Are you legally eligible for employment in the United States?
*
Yes
No
STOP WE ONLY DO BUSINESS WITH PEOPLE ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES
Can you provide Revolutionary Designz, LLC your resume?
*
Yes
No
Please download your resume. (The only files accepted are Microsoft Word Documents and PDF)
Accepted file types: docx, doc, pdf, Max. file size: 64 MB.
Do you have your W9 Form?
Yes
No
What is this?
Please click here to get a copy of your W9 Form
YOU WILL NEED TO SIGN AND DATE THIS FORM.
Please download your W9 Form. (PDF is the only acceptable format)
Accepted file types: pdf, Max. file size: 64 MB.
MILITARY
Are you a United States Military Veteran?
Yes
No
What type of seperation from the military do you have?
*
Honorable Discharge
Dishonorable Discharge
Medical or Disabled Discharge
Please provide your DD214 papers. (The only files accepted are Microsoft Word Documents and PDF)
Accepted file types: pdf, docx, doc, Max. file size: 64 MB.
INFORMATON TO THE APPLICANT
As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job . You may make a written request for information derived from the checking of your references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above.
By saying yes you agree to the above information title "Information to the Applicant" Do you agree?
*
Yes
No
Please place your initials here to agree.
*
Date
Month
Day
Year
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