__Back_to_Affiliate_Area__
__heading__
*
Indicates required fields.
__AFFILIATE_URL__
User Name
*
__username__
Password
*
[Must be from 5 - 15 numbers or letters and not include spaces or special characters]
Confirm Password
*
[Enter the same password again]
First Name
*
Last Name
*
Affiliate Name:
This name will be displayed on home and oto page if any referal will come through your affiliate URL.
Address1
__address1__
Address2
__address2__
Business Tax ID Number
(Fill in your official business tax ID number 00-0000000).
State / Province
*
Zip Code
*
Phone
*
Fax
Social Security Number
For US Citizens only. Due to tax laws in the U.S. You must type in your SS# (000-00-0000) if you are a U.S. citizen filing as an individual on your tax returns. If you file as a company please complete the Company Name and Business Tax Id fields below.
Email Address ID
*
Yahoo IM
Company Name
(Fill in your official company name here such as XYZ Inc, LLC, LP).
Sponsor
Skype
Alternative Email
Pay Me By:
__paymeby__
__fields_rows_p__ __CUSTOM_FIELDS__ __comments__
__RegistrationDate__
__signupdate__
__RegistrationIP__
__signupip__
__tiers_fields__ __suspend_affiliate__ __CAPTCHA__ __unsubscribe_affiliate__ __toc__ __affiliate_special_offer__ __jv_affiliate__