__SITE_NAME__ Affiliate Program
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[Must be from 5 - 15 numbers or letters and not include spaces or special characters]
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.]
Address 1*:
Address 2:
City:
State:
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Zip*:
Phone:
Primary Email: *
Alternative Email:

All commissions will be paid straight to your Paypal.com account unless you request to be paid via check.
Pay Me By: PayPal
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Paypal Email Address ID: __ASTRIC__

Please type in your Paypal email address in order to be paid commissions due.

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.

Company Name:
(Fill in your official company name here such as XYZ Inc, LLC, LP).

Business Tax ID Number:
(Fill in your official business tax ID number 00-0000000).

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