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Affiliate Application

By filling out and submitting this form you are applying to be an AGNRG.com affiliate. Upon submission of this form, a 24-hour-per-day, order-taking, replicated web site will be activated for you.


Affiliate Prefix:


 

Example: xyz.AGNRG.com. If the affiliate prefix you enter has already been taken, you will have to choose a different prefix.


Affiliate Prefix: Any combination of letters and numbers to that go in front of AGNRG.com to uniquely identify your affiliate sales (so you get paid).

Back Office Password:
Minimum of 5 character

 

Password: Using your affiliate prefix and password is the only one you can access your back office.

First Name:

 

First and Last Name, Email Address, Day Phone, Evening Phone: Communications about your affiliate account will be made to this person at the email address you enter, and possibly to your phone numbers.

Last Name:

 

Email Address:

 

Day Phone:

 

Evening Phone:

 

 

 

 

Payee Name:

 

Payee Name and Address: Commissions are sent via check to this person or organization.

Payee Address (Line 1):

 

(Line 2):

 

Country:

City:

 

State or Province:

 

Postal Code:

 

 

 

 

Paypal Address:

 

Paypal Address: If you enter a Paypal address, commissions will be sent through Paypal (you will lose a small percentage of your commission to Paypal).

Web Site Phone Number:

 

Web Site Phone Number and Toll Free Number: These phone numbers will appear on the Contact Us page of the webs site. Putting your numbers here means that you will be responsible for answering sales/customer service phone calls.

Web Site Toll Free Phone Number:

 

Tax ID:

 

U.S. Tax ID: if you are subject to U.S. tax laws, then you must provide a TAX ID number. Click here for more info.

Clicking Submit indicates that you have read and agree to all the terms outlined in the Affiliate Agreement. Please enter your initials to indicate that you are digitally signing this agreement.

IP Address:

54.81.88.93 

 

 


By clicking submit, I agree to the terms of the Affiliate Agreement.