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| 16 Nov 2024
New Affiliate Registration
Please note that the field marked with
*
are mandatory.
System Information
User Name:
*
Please type in a user name (only latin alphabet characters and digits).
Password:
*
Password should have between 4 and 12 characters.
Retype the password:
*
Site
Site Title:
*
Url:
*
Billing Information
Company:
First Name:
*
Family Name:
*
Address:
*
City:
*
Province/State:
ZIP/Postal Code:
Country:
(Choose a country)
*
Telephone:
*
Fax:
E-mail:
*
Payment Method:
Cheque
Bank Tranfer
Please fill the fields below only if you selected bank transfer payment method
Name of the Bank:
Code/SWIFT of the Bank:
Account Holder:
Bank Account:
Bank Address:
Other Info/Remarks:
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