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Be An Ambassador

PerfectShaker Ambassador Form

Hello! We are very excited you decided to submit your application and are very interested in getting to know you a bit better.
* Required
 
 
First Name *
 
Last Name *
 
Email Address *
 
Address *
(Where product and payment could be sent)
 
Address Line 2
(Don't forget your unit number)
 
City *
 
State / Province *
 
Postal Code / ZIP *
 
Phone Number *
 
Date of Birth *
   
 
 
Sex *
 
Twitter Profile
 
Twitter Followers
 
Facebook Likes
 
Instagram Account
 
Instagram Followers
 
Blog Name
 
Blog Website Address
 
Unique Monthly Visits to Blog
 
Youtube Subscribers
 
Do you have an inspiring story to tell?: (max 150 words)
 
What are your personal/health/fitness goals for the next year: (max 150 words) *
 
Why do you feel you would make a great PerfectShaker Ambassador?: (max 150 word)
 
In what way(s) will you represent PerfectShaker? Where could you feature the PerfectShaker brand?: (max 150 words)
 
Are you open to a product rate sponsorship if that is available?