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General Information
First Name: Last Name:
Middle Initial*: Email Address:
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NOTE: Passwords must be at least four characters in length and consist of alphanumeric characters only.
Contact Information
Street Address: City:
Country: State:
Zip Code: Province (outside of the USA):
Phone Number: Fax Number*:
 
Payout Information
Do not send me order notifications via Email:
Please choose the method by which you'd like to be paid: Check
Make checks payable to:
Issue payment when the balance of my account reaches: $ $50 min.
Site URL:* http://
Please enter in the form "www.mysite.com" - do not include "http://".
Site Type*:
# of Site Visitors, Monthly*:
Business Name*:
 

US residents must provide a Social Security Number OR a Federal Tax ID Number in order to get paid. Federal law requires that we send you a 1099 at the end of the year. International applicants are welcome and do not require a Social Security number.

Social Security Number: - - ***Please enter all zeros(0) if not applicable
Tax ID Number: - ***Please enter all zeros(0) if not applicable
 

Please review the Affiliate Agreement which describes the terms and conditions of your participation in the SelfServeRx Affiliate Program. Once you have completed this form and reviewed the agreement, press the "Submit" button below to submit your application.

If your application to participate in the SelfServeRx Affiliate Program is accepted, you hereby agree to be bound by the terms and conditions of the operating agreement which you hereby state to have read and understood.

NOTICE: Once this application is approved, confirmation and setup instructions will be emailed to you so please make sure your email address is correct.

Submitting this registration form indicates that you have have read and agree to the terms and conditions in the Affiliate Agreement. (Please click only once.)

 
 
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