Affiliate Sign Up - Amplify Affiliates

Username *

Required 4 characters.

Password *

Required 8 characters.

Confirm Password *

Required, equals Password.

First Name *

Email Address*

Company Phone Number

Website URL *

e.g: http://www.examplexyz.com

City *

Zip Code *

Skype ID

Required minimum 4 characters

Last Name *

Company Name

VAT Number

Company Registration Number

Phone Number *

Address *

State/Province

Country *

Payment Settings*

Bank Transfer BitCoin Details

First Name *

Last Name *

IBAN *

Account Number *

Bank Name *

Swift/BSB *

Address (line 1) *

Address (line 2)

City *

State/Province *

Country *

	Brand	Website URL
	Fatbet	https://fatbet.com/

I accept the Terms and Conditions For Amplify Affiliates.

[Note : Mandatory fields are marked with an asterisk (*)]