Affiliate Program - Sign Up

Your Personal Details	* Required information
First Name:	required
Last Name:	required
E-Mail Address:	required
Sales Email Notification:	Check here if you want to be notified when a sales is made

Selected Method

Payout Currency:	required
Bank Name:	required
Branch Name:	required
Bank Address:	required
Bank City:	required
Bank State:	required
Bank Postcode:	required
Bank Country:	required
Account Holder Name:	required
Account Number:	required
Bank Routing No:
ABA / SWIFT Code:	required
Account Class:
Account Type:

Your Address
Address:	required. Eg. 6 Smith Str - NB: NOT Smith Str 6
Suburb:
City:	required
Post Code/Zip Code:	required
State/Province:	required
Country:	required

Your Contact Information
Telephone Number:
Fax Number:
Homepage:	required (omit http://)

Your Password
Password:	*
Confirmation:	*

Options
Affiliate Newsletter

Check here to indicate that you have read and agree to the Affiliate Program Terms and Conditions