EmailMe Form - PCMP - Business Advertiser Verification Form

Business Name (as it appears on your SS-4) *

Business Address (as it appears on your SS-4) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Business Form SS-4 File Upload *

Please upload a a CLEAR image of your Business Form SS-4. Please note that this CANNOT be a completed W-9.

Owner's Name (as it appears on your Driver's License) *

First Last

Owner's Address (as it appears on your Driver's License) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Owner's Driver's License Upload *

Please upload a CLEAR image of the Front AND Back of your Driver's License in a JPG or JPEG file format only. These cannot be scanned images, they must be a clear picture of the front AND the back of the license.

Phone *

### - ### - ####

Email *

Signature *

Clear

By signing this form, I authorize Patient Care Marketing Pros ("PCMP") to collect and use a my Driver's License and our Business EIN Form solely for business advertiser verification purposes. I understand that this document will be stored securely and used exclusively for business advertiser verification processes required by the advertising platforms agreed upon for my account, which may include, but are not limited to, Google, Facebook, YouTube, and TikTok.