Graphix Image Referral Form
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Please use this form to Refer a project for either products or services. 
Information with * is required  so that we may respond promptly to your request.  Thank you!

All information submitted to GraphiXImage will remain confidential.
All Commissions and referral fees are either paid by check or applied towards services.
Commissions and referral fees will be paid in full once referred project is completed and paid for.
© Copyright 2001-2008  GraphixImage  All rights reserved.                                             A Division Of Tribay Media Group Inc.

           

Affiliate's Information:
*First Name:
*Last Name:
*Company Name:
Customer Acct #:
*Phone:
Fax:
*E-mail:
Web Address:
Referred Company or Party Information:
*First Name:
*Last Name:
*Company Name:
*Phone:
Fax:
*E-mail:
Web Address:
Please have an Account Representative contact me by:
Phone E-mail
Referral fee payment preference:
Certified Check Apply Towards Services
Products & Services Requested :
Comments or Questions: