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Welcome to our affiliate program. Please complete the form below to signup.

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* Business type: If you are applying for an affiliate account as an individual or a sole trader, please select “Individual” If you are applying for an affiliate account on behalf of a company {including partnerships}, please select “Corporate”

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* How will you market us?

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If yes, please list the license(s) held: Vendor Major/Minor License/States Licensed ID#

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Exempt Payee Code (If Applicable)

Exemption from FATCA reporting code (If Applicable)

* Tax Address (number, street, and apt. or suite no.)

* Tax City, State, and ZIP Code.

* Tax Payer Identification Number

* Terms & Conditions Please read the Terms & Conditions before agreeing.

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* Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

I confirm.