Affiliate Sign Up - Galaxy Affiliates

Username *

Required 4 characters.

Password *

Required 8 characters.

Confirm Password *

Required, equals Password.

First Name *

Email Address *

Company Contact 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 Number

Contact Number *

Address *

State/Province

Country *

Payment Settings *

Bank Account Details Paypal Details BACS Details Neteller Details

First Name *

Last Name *

IBAN *

Account No. *

Bank Name *

Swift/BSB *

Address1 *

Address2

City *

State/Province *

Country *

	Brand	Website URL
	Jackpot Paradise	www.jackpotparadise.com
	Jackpot Mobile Casino	www.jackpotmobilecasino.co.uk
	Swanky Bingo	www.swankybingo.com
	Vegas Mobile Casino	www.vegasmobilecasino.co.uk
	The Online Casino	www.theonlinecasino.co.uk
	Cosmic Spins	www.cosmicspins.com
	Swift Casino	www.swiftcasino.com
	Fortune Mobile Casino	fortunemobilecasino.co.uk

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