Proxyconn Affiliate Signup



AFFILIATE SIGNUP (Proxyconn staff only)

*1. Payee Information ( required fields )**

*Name:
	Enter name exactly as it should appear on the check
*Address:
Address 2:
*City:
*State:
*Zip code:
*Country:
Phone:

2. Business Information		Check here if same as above

*Name:
*Address:
Address 2:
*City:
*State:
*Zip code:
*Country:
Phone:

3. Log-In Information

*Contact Email:
	Serves as Log-in ID.

*Create Password:
*Confirm Password:

4. Website Information		Fill in at least one field

Website URL:
	Separate multiple URLs by a semicolon.

Newsletter Name:
	Separate multiple names by a semicolon.

Other:
	Email, Banner ads, etc.
By clicking the "Signup" button below, I acknowledge that I have read and have understood all the terms and conditions of the Affiliate Agreement and I agree to be bound by each of the terms of the Affiliate Agreement.