Make Your Life Count Affiliate Referral Application 
Thank you for helping me make real change in the world.

The following form has been created to gather your details so I can ensure a swift and fast payment for any referrals you send to me.

Your data is important and will be held securely and only used for the purposes of this scheme.

If you wish to withdraw consent from me holding this information and you wish to withdraw from the scheme please email

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Your First name *
Family name *
Best Contact Telephone Number *
Business name if applicable
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