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Thank you for choosing to set up a new affiliate account. Just complete the information below and click the 'Submit' button to set up a new affiliate account. The affiliate code you choose should contain only alpha (letter) and numeric (number) characters.

* - Denotes a required field.

Affiliate Code *

Password *

First Name *	Last Name *
Company Name	Address Line 1 *
Address Line 2	City *
County/State/Province *	Country *
Post Code/Zip *	Residential/Commercial *
Telephone Number *	Fax Number
Email Address *