__SITE_NAME__ Affiliate Program
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Sponsor: __sponsor__
Affiliate URL * __AFFILIATE_URL__
Username: *
[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]
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:
Country*: __COUNTRY_SEL__
Zip*:
Phone:
Cell Phone:
Fax:
MSN IM
Yahoo IM
Skype
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
Check
Paypal Email Address ID:

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).

__CUSTOM_FIELDS__
Affiliate special offer.
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