New Affiliate Intake Form Please fill out this form to get onboarding started. Items marked with a asterisk are required fields. Proposed Agency Name* Principal First Name* Principal Last Name* Preferred Name Principal Agency Partner(s) Name(s)* Domiciled State* Personal Street Address* City* State* Postal Code* Office Street Address City State Postal Code Mobile Phone* Office Phone Office Fax Work Email* Website Down Payment Amount* Onboarding Fee Payment Plan* Number of Planned Epic Seats Needed* Planned Agency Launch Date* (mm/dd/yyyy) Number of Complimentary EZLynx/Epic Months* Please Specify Any Concessions Offered:* Any Existing Codes or Books?* Referral Source Referral Payment Amount Staff Info* Δ