Affiliate Application Form

Your information for affiliate account set up
Name*
First Last
Email*

This will be the email address used to set up your affiliate account and will also be your login.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your commission payment information
How would you like your commission to be paid?*
- Check
- PayPal
If you like to get paid by check, is your address to send the check to the same as listed above?*
- Yes
- No (if it isn't please enter address for check below)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email associated with your PayPal account

Only relevant if you want your commission paid out via PayPal.
Which of our programs would you like to promote?
Please select all the programs you are interested in promoting and we will set you up with an affiliate link for the programs you select.
Public Programs (support programs to use with your clients)*
Professional Programs (online education for health care professionals)*

Your information for affiliate account set up