Referral Ambassador Survey - BioCollections Worldwide, Inc.

Your Contact Information

Full Name *

Email *

Phone *

City / State

Contact & Basic Eligibility

Are you 18 years or older? *

Yes No

Are you legally authorized to work as an independent contractor in the U.S.? *

Yes No

Network & Reach

Experience & Fit

Have you done referral-based or commission-based work before? *

If yes, please provide a brief description

Yes No

Have you worked in healthcare, clinical research, or patient advocacy? *

If yes, please provide details

Yes No

Why are you interested in this opportunity? *

Target Population Match

Which of the following donor/participant categories do you feel you could realistically refer? * General healthy donors Specific condition donors Specific demographic groups

Estimated number of qualified referrals you could generate per batch/cycle *

Note: minimum batch size is 25 participants

25-49 50-99 100-249 250+

Logistics & Compliance

Are you comfortable completing a 1099 independent contractor agreement? *

Yes No

Do you agree to follow BCW's referral guidelines and compliance/privacy requirements? *

See referral guidelines and compliance/privacy requirements (link to terms)

Yes No

How did you hear about this opportunity? *

Ambassador Reimbursement

Please select your preferred method of payment for reimbursement