MPA3
Affiliate Registration Form
1. Website Information
Company *
Website URL *
2. Contact Information
Email Address *
First name *
Last name *
Telephone Number *
ICQ Number
Skype Name
3. Payment Information
Beneficiary Name *
Address *
City *
State / Province *
Outside US/CA
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
Fed. St. of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Is.
Northwest Territories
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Yukon Territory
Zip Code *
Country *
United States
Tax ID / S.S. #
If US Resident
VAT #
If EU Resident
Payment methods:
Check
Wire
The following information needed if paid by i-Payout
i-Payout Email
The following information needed if paid by Paxum
Paxum Email
The following information needed if paid by CashX
CashX Email
The following information needed if paid by Wire
Account Number
SWIFT code
ABA code
Bank Name
Bank city
Bank Country
Bank IBAN
Bank BIC Code
Payments by Prepaid debit MasterCard®:
Please apply by visiting the "Account Settings" page after completing webmaster registration.
4. Funds Distribution
Minimum Payout : $
50
100
150
200
250
500
1000
1500
2000
2500
3000
5000
10000
5. Login Information
User name *
Password *
Note: Use alphanumeric and underscore (_) characters only. Limit: 6-12 characters.
Verify Password *
6. Affiliate Representative
Affiliate id
None
100172 - Bill Rust
7. Write the following word
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