Referral Program Application

Referral Partner First And Last Name:(required)

Referral Partner Email:(required)

Referral Partner Phone Number:(required)

Preferred Method of Contact:(required)

Text Phone Call Email

Referral Partner Address:(required)

Referral Partner City, State, Zip Code:(required)

How would you like to receive commission?

Venmo CashApp PayPal Check Via Mail

If you selected Venmo or CashApp, please enter your username. If you selected Paypal, please enter the email address linked to your Paypal account.

Would you like a custom coupon code created?(required)

Yes (for automatic tracking) No

If yes above, please enter your proposed custom coupon code. It's best to keep it simple with a name or name/number combo. Example: CASEY25

For birth professionals: Would you like your logo & information added to our Partners Page?

Yes No

Do you need any printed materials mailed to you? (business cards, tri-fold pamphlets, etc.) If so, please leave a note before for desired type of material, quantity, and preferred address for sending.

By checking this box you agree that commission payout at this time is $25 per referred client.(required)

By checking this box you agree that it may take up to 1 week to receive commission payout.(required)

By checking this box you agree that commission accrued over $600 will be held until a Form 1099-Misc is completed and returned.(required)

By checking this box you agree that commission payout request form (if applicable) needs to be submitted within 1 month of referred client's encapsulation date. (not needed for partners using custom coupon codes for automatic tracking) (required)

By checking this box you agree that you are 18 years or older. By checking this box if under 18, you agree to review and submit with parent/legal guardian.

By clicking submit below you agree to to the following terms and conditions: The Midwest Placenta Encapsulation referral program can cease or change at any given time. This service has not been evaluated by the FDA. Services offered are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Successors, agents or assigns, hereby unconditionally release Midwest Placenta Encapsulation, its owners, officers, employees, agents, successors in interest and insurers, heirs, executors, administrators, assigns, agents, trainers, placenta preservation certifying association, representatives, and all others acting on their behalf, from any and all claims, actions, damages, liabilities, injuries, losses, costs, and expenses, including, without limitation, attorney’s fees, in any way arising out of, or resulting from, referral of placental services and products. All rights reserved, materials are copyright protected will not be used/duplicated/recreated for personal gain. Please let us know if you have any specific questions below.