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Main page :: Profile details

Customer Sign Up Form

The form below allows you to create a profile for our affilate program which is necessary to see banner statistics, orders and payments.
Checks will be made out and sent to the address provided below, so accurate information on your initial application is essential to become a partner. Each application will be researched for accuracy before approved.

The fields marked with * are mandatory.


Profile details
Personal information
Title *
First name *
Last name *
Company *
SSN# or Corporation EIN# *
Tax number  
Billing Address
Title *
First name *
Last name *
Address *
Address (line 2)  
City *
State *
Country *
Zip/Postal code *
Contact Information
Phone *
E-mail *
Fax  
Web site *
HOW DID YOU HEAR ABOUT ADULTCON?
STREET BILLBOARD
FREEWAY BILLBOARD
WEBSITE
RADIO KLOS 95.5
NEWSPAPER
FROM FRIENDS
BEEN THERE BEFORE
BEEN TO THE LAST SHOW
GOT A FLYER
Affiliate plans
Signup for partner plan  
Username & Password
Username *
Password *
Confirm Password *


Clicking "SUBMIT" you agree with our "Terms & Conditions"
 
SubmitCustomer Sign Up Form


Information

We recommend that your password should be at least 5 characters long and should be different from your username.

Your e-mail address must be valid. We use e-mail for communication purposes (order notifications, etc). Therefore, it is essential to provide a valid e-mail address to be able to use our services correctly.

All your private data is confidential. We will never sell, exchange or market it in any way.
For further information on the responsibilities of both parts, you may refer to our
Terms & Conditions 
 
 


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