Welcome to the Ambassador Affiliate Inquiry Form

Once your form is submitted, someone from our Affiliate Team will be in touch within 2 business days. We appreciate you checking us out!

Ambassador Affiliate Form

First Name*

Last Name*

Email Address*

Cell Phone Number*

Company Name (not required)

Your Website

Address Information

Street Address*

Street Address Line 2

City*

State*

Zip/Postal Code*

Country

Other Information

How do you plan to promote ENERGYbits? *

What Market Segment best describes your business or audience?

Anything else to share?

How did you hear about us?

Referred by someone? Details (optional)

Create your ENERGYbits Coupon code (4-10 characters, do not use any numbers or the words "ENERGY" or "BITS")

For commission payment, please provide your Tax ID:

Email for PayPal commission payments:

For commission payment, upload completed W-9:

Tell us about your Social Media

Facebook Username

Instagram URL

LinkedIn Profile

Terms and Conditions

Please Checkbox to Agree To Our Terms and Conditions* Click to view our terms and conditions