PLATINUM MEMBERSHIP APPLICATION

Full Name*

First Last

Stage Name*

Genre

Rap/Hip Hop
R&B/Soul
Pop/Alternative
Other

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Email*

Website

Provide best contact # (US members) if outside US enter full number and country code for international calls.*

I am 18 years of age or older*

Yes
No

Were you referred by one of our affiliates or brand ambassadors?*

Yes
No

Please enter affiliate name and Rep ID or brand ambassador promo code

Affiliate Name

Rep ID/Brand Ambassador Promo Code

Which membership services are you most interested in?

Digital Radio airplay
Magazine Advertisement
Online marketing/Promo
Certified Seller Discounts
Artist Reward Points
Expert Advice/Support
Networking/Connects

Social Media Handles

Instagram

Twitter

Facebook

Soundcloud

How did you hear about us?

Google
Bing
Other search engine
Affiliate/Friend
Online Ad

Member Electronic Signature*

I hereby acknowledge that I have read, understand and agree to all terms and conditions of becoming a member of the Industry Certified program and agree to abide with all membership guidelines, best business practices, membership rules and regulations for my services.

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

Membership Effective Date*

MM

DD

YYYY

Please enter affiliate name and Rep ID or brand ambassador promo code

Social Media Handles