19995 SW Stafford Rd.
Portland Oregon 97068
  

Fax this form to

503-673-0259




CASH REWARD PROGRAM REGISTRATION FORM

Name: Home Phone: (     )
Mailing Address: Work Phone: (     )
City:                            State:            Zip: Cell / Pager: (     )
Social Security #: Email Address:

ACKNOWLEDGEMENTS

I hereby acknowledge and agree that:

  1. I am not an employee of
  2. I am responsible for any income tax liability and for notifying the IRS of my earnings
  3. If I earn $600 or more during any calendar year, will issue a 1099 IRS Form for tax purposes as required by law.
Signature
Date

Fax to 503-673-0259 or mail to

19995 SW Stafford Rd.
Portland Oregon 97068