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Fields marked with an * are required fields.

*Choose a Username:

(min 5 characters - max 20 characters - letters or numbers only)

*First Name:		Primary Site Name:
*Last Name:		Primary Site URL:
*Email Address:		*Phone Number:
Company:		Fax Number:
*Address:		Skype Name:
Address (cont'd):
*City:
*State/Province:
*Zip/Postal:
*Country:
GST Registered?:	No Yes
GST Number:

* Please note: As part of your program signup, you will receive email notifications and updates from Sellhealth.com.
If you choose not to receive these, you can opt out after signup.

*Please choose one of the following payment options and fill in the required field. Wire Transfers and ACH account names can be configured within the affiliate interface after your account has been created. Wire Transfers have a minimum payout level of $500 to offset the cost of transaction. Your choice is not permanent. You can change your method of payment later, if desired.

	Standard Check		Name on Check:
	Wire Transfer		Details can be entered within the affiliate interface.
	PayPal		Email Address:
	ACH (USA Only)		Details can be entered within the affiliate interface.
	Paxum		Email Address:

*As an affiliate, how would you best describe your experience level?

*Which traffic source do you have the most experience with?

	I have read and agreed with all of the terms & conditions*
	I have read and understand the new U.S. Federal CAN-SPAM Act* and the potential fines that may result.