Affiliate Registration – Mushroom State

First Name *

Last Name *

Email *

Mobile *

Please enter your mobile number

Venmo Username for Payment *

Venmo name to send affiliate payouts.

Social Media *

Please enter a link to one of your social accounts.

Who Referred You? *

Please enter the First and Last name of the person who referred you to the affiliate program.

How will you promote the site?

Password *

Password Confirmation *