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
	Cloud Casino	www.cloudcasino.com
	Swanky Bingo	www.swankybingo.com
	Vegas Mobile Casino	www.vegasmobilecasino.co.uk
	The Online Casino	www.theonlinecasino.co.uk
	Cosmic Spins	www.cosmicspins.com

I accept the Terms and Conditions for Galaxy Affiliates programme.

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