First Name

Last Name

Business Name

Your Position

Website Address

Zip Code

Phone Number

What type of services do you provide?

In a few sentences, tell us about your business.

Tell us why you are interested in this program.

If accepted, which structure would you prefer for participation in the Performance Partnership Program?

Flat monthly fee (no equity shared)

Fractional equity or profit share arrangement (in lieu of upfront fees)

Do you authorize Element 99 Web Services to review your application, conduct a basic business search, and contact you with additional details if needed?

Yes

Authorization

By submitting this form, you verify that you are an authorized representative of your business and have the authority to provide this information and enter into discussions on its behalf. You authorize Element 99 Web Services to review your application, conduct a basic business search, and contact you for additional information as part of the pre-qualification process. If selected for pre-qualification, you may be asked to provide supporting documents such as financial statements and organizational records. All information submitted will be kept confidential and used solely for evaluating eligibility in the Performance Partnership Program.

Signature

Please sign below to submit this form.