webmaster's join form

1. Website Information
Company *
Website URL *

2. Contact Information
Important: You will be required to respond to an email to activate your account so you must use a valid email address.
Email Address *
First name
Last name *
Telephone Number *
ICQ Number
Skype Name

3. Payment Information

Beneficiary Name *

Address *
City *
State / Province *
Zip Code *
Country *
Tax ID / S.S. # If US Resident

If EU Resident

Affiliate Payments are only made via Paxum. You must have an account with Paxum (www.Paxum.com) and provide the email address for your Paxum account in order to receive payments.

Paxum Email

4. Funds Distribution
Minimum Payout$

5. Login Information
User name *
Password *
Verify Password *
Note: Use alphanumeric and underscore (_) characters only. Limit: 6-12 characters.

6. Affiliate Representative