New Referral Partner Submission

New Referral Partner Referral Submission

Please complete the form below with your information. You will be required to provide Part 1 information only once. Fields indicated with an * are required.

Part 1: Referral Partner Information
Name*
First Last
Organization / Sole Proprietor Name*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Phone Number*
Fax Number
Are you submitting this referral as a business or as an individual*
Should this referral qualify for payment, please provide payee's name*
(address and contact info provided above will be used)
Upload a completed W-9
Max. file size: 3 MB.
Click here to download the IRS W‐9 Form. This document must be completed and signed prior to payment.
Please select payment preference*
- Check
- Direct Deposit
Note: if direct deposit is selected, bank details will be requested and confirmed in an email. 
How did you learn of this Program?*
Additional Comments
Do you wish to submit a referral at this time?*
- Yes
- No
Part 2: Referral Information
Please complete the following information on your client’s behalf. We will contact them based on the information you provide. This information will be required for each referral submitted.
Referral Contact Information*
First Last
Email*
Enter Email Confirm Email
Daytime Phone Number*
State
Interest Timeframe*
Primary Investment*
When should Pango Financial contact this client?*
- ASAP
- Prospect will contact Pango Financial
- Contact on or after a date
What date would you like Pango to contact this client?
MM slash DD slash YYYY
Additional Notes
Disclosure
The program is governed by the Pango Referral Partner Terms & Conditions. If you do not wish to be bound by the terms and conditions, then do not submit the Referral Submission Form. However, if you are in agreement with these official rules and wish to proceed, please read and attest to the following statement. Pango Financial reserves the right, in its sole discretion and without further notice to you, to revise any of the terms herein at any time.
A copy of this Referral Submission Form will be sent to the email address that you entered in Part 1. Please direct all future communications regarding this referral to support@pangofinancial.com.
A copy of this Referral Submission Form will be sent to the email address that you entered in Part 1. Please direct all future communications regarding this referral to support@pangofinancial.com.*
- I acknowledge that I have read and accept the Pango Referral Partner Terms & Conditions. I agree to be bound by these terms and conditions.
  
  By submitting this information, I am providing evidence of my agreement.
Comments
This field is for validation purposes and should be left unchanged.

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New Referral Partner Referral Submission

Part 1: Referral Partner Information

Part 2: Referral Information

Disclosure

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