Affiliate Application Form

Vendor Accounts Details
Please enter the relevant contact details for someone in your Accounts department.
Contact Name:*
Contact Email:*
Phone Number:*
Bank Account Details
Please enter your bank information for payment purposes.
Bank Name:*
Branch Address:*
Street Address Address Line 2 City State / Province / Region Postcode Country
Account Name:*
Account Type:*
e.g. Cheque/Savings
BSB:*
Account Number:*
IBAN Number (if applicable):
Brand Identifier (if applicable):
SWIFT Code/CHIPS UID Number (if applicable):
Declaration/Acknowledgement
By completing and submitting this application, the Affiliate described above acknowledges that it has read, understands and accepts the Affiliate Program Terms published here.

The Authorised Person nominated in this application warrants and represents to LocaliQ that:
• the information they have provided in the Application Form is true and correct in all respects; and
• they are authorised to enter into an Agreement (comprised by this Application, the Affiliate Terms and LocaliQ written acceptance of the Application) on behalf of the Affiliate and they remain responsible for the performance of that Agreement by the Affiliate.

Your application will be assessed by us and you will be contacted by one of our team. LocaliQ will notify you via email as to whether your application has been accepted or declined. LocaliQ reserves the right in its absolute discretion to accept or decline any application from any organisation or individual.
By completing and submitting this application, the Affiliate described above acknowledges that it has read, understands and accepts the Affiliate Program Terms published here.

The Authorised Person nominated in this application warrants and represents to LocaliQ that:
• the information they have provided in the Application Form is true and correct in all respects; and
• they are authorised to enter into an Agreement (comprised by this Application, the Affiliate Terms and LocaliQ’s written acceptance of the Application) on behalf of the Affiliate and they remain responsible for the performance of that Agreement by the Affiliate.

Your application will be assessed by us and you will be contacted by one of our team. LocaliQ will notify you via email as to whether your application has been accepted or declined. LocaliQ reserves the right in its absolute discretion to accept or decline any application from any organisation or individual.
Commission % Rate (% of Net Collected Revenue)
Below $25,000 | 5.0%
$25,001 - $50,000 | 6.0%
$50,001 - $100,000 | 8.0%
$100,001 - $150,000 | 10.0%
$150,001 and above | 12.0%
LocaliQ reserves the right to amend and change the Commission % Rate and Commission Tiers in the table, without 3rd party approval, provided 30 days notice is provided of any such change.
As an officer or owner of the Vendor, by submitting this form, I declare that the information contained in this application is correct and factual and not false or misleading in any respect.
Declarer's Name:*
Declarer's Title:*
Signature*
Effective Date:*
DD slash MM slash YYYY

Vendor Details

Director Details

Vendor Accounts Details

Bank Account Details

Declaration/Acknowledgement

Commission % Rate (% of Net Collected Revenue)

LocaliQ reserves the right to amend and change the Commission % Rate and Commission Tiers in the table, without 3rd party approval, provided 30 days notice is provided of any such change.