New Affiliate Intake Form

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*

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