21 Affiliates: Affiliate Program Signup

Affiliate Program Signup

Please only enter a company name, if you have a registered company, as all payments will be made out to the company name entered here. If you have a registered company please also enter your Tax ID/VAT No.

Your Username must be one single word containing letters and/or numbers only.

Account Information
Login: *	Login name must be one word with alphanumeric symbols only. Please don't use special characters.
Password: *	Password is sensitive to a keyboard layout.
Repeat Entry: *	Password is sensitive to a keyboard layout.
Personal Information:
Title: *
First name: *	Please, enter your real name.
Last name: *	Please, enter your real family name.
Address 1: *
Address 2:	This field is optional.
Address 3:	This field is optional.
Town/City: *
State/Province/Region:
Zip/Postal Code: *
Country: *
Business Information
Company:	Leave blank if this is not a company account
Website: *	If you do not have your own website please provide the URL of the page where you will be displaying advertisements such as a facebook or twitter account URL. Please ensure you use a valid site address such as http://www.sitepage.com or https://www.sitepage.com
Tax ID (VAT ID):
Contact Information
E-mail: *
Instant Messenger:
Phone number:
Fax number:	This field is optional.
Account Settings
Preferred Currency: *
Preferred Method of Contact: *
Preferred Language: *
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Signup Verification
Enter the code: *	Please try using an alternative image

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