Affiliate Application Form for
 The Key To Successful Weight Loss Program

IMPORTANT: Please READ the Affiliate Agreement document
 before you fill in this form or your entry will be erased.
  Your Name:
  Mailing Address:
  City:
  State/Province:
    Enter only if you reside in
         the US or Canada
  Postal/Zip Code:
  Country:
  Phone Number:
     include area code
  Fax Number:
    include area code
  Email:
    Triple-check your email
     address, If it's wrong,
     we can't pay you.
 Web site URL (address):
  You can succeed in our
  Affiliate Program without a
  web site. If you do not have
  a site, type "none" in this
  space.
  Name of Referral:
    Type in the full name of
    person/site who referred you to
    our program.  Indicate their
    ID#  (if you know it.) If no-one
    referred you type "none".
Affiliate Details:  
We need to know if we should pay you personally, or your company.                   
                                Check here if you want us to pay you personally.
                                            If so, do not fill in the company box below.
Please provide your SS# (in USA) by sending it to us by FAX (at 908-904-9300) or mailing it to us. We do not recommend sending this information over the Internet. (In the U.S. this information is necessary for tax filing purposes).
If you prefer your checks to be made to a company name, please enter the exact name in the space below.  (Also provide your company's Federal ID# for tax filing purposes)

Your Company Name:

   

Company Federal ID#:

Review Affiliate Agreement and Submit

     If you agree with the terms of this Agreement, press the "I Agree!" button (below) to submit your application.  If we accept your application, you hereby agree to be bound by its terms and conditions.

Upon acceptance, we will e-mail you...

  ▪ Your User Name and Password for access to the Affiliate Log-in web page.

   ▪ Easy setting-up and income-maximizing instructions.

If you have any problems with the application process, please e-mail us.

                                       

Your application is complete.

Return to Home Page