EmailMe Form - PCMP - Driver's License Verification for Ad Spend

Business Name *

Full Name (As Appears on Driver's License being submitted)

First Middle Last

Phone

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

Email

Driver's License Image (Front) *

Please upload a CLEAR image of the FRONT 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 of the license.

Driver's License Image (Back) *

Please upload a CLEAR image of the 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 back of the license.

Signature *

Clear

By signing this form, I authorize Patient Care Marketing Pros (“PCMP”) to collect and use a copy of my driver’s license solely for identity verification purposes. I understand that this document will be stored securely and used exclusively for Ad Spend 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.