Kickback Membership Form

MEMBERSHIP FORM

Name *

Name

First Name

Last Name

Company or Artist Name: *

Location *

(i.e. New York, LA, Atlanta)

Email Address *

Website

Example: www.mrtruthcity.com

Faceook *

Example: www.facebook.com/johndoe

Twitter

Example: @janedoe

Instagram *

Example: @johndoe