Affiliate Registration - DermOne Health and Wellness

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Affiliate Registration Form
Wholesale Affiliate Registration Form
Charity Affiliate Registration Form
Name*
First Last
Username*
Password*
Enter Password Confirm Password
Sponsor Name (person who recommended you, leave blank if no one)
Company (if applicable)
Address*
Street Address Suite or Box Number City State / Province / Region ZIP / Postal Code Country
Email*
Your Website, Blog, Instagram, Linkedin, Facebook, Twitter*
Cell Phone (add country code, if known)*
Social Security Number or Business Tax ID
Date of Birth*
Date Format: DD slash MM slash YYYY
I wish to be registered as:*
- Affiliate Entrepreneur
- Influencer or Public Figure
- Group or Association
Is your organization tax exempt 501(c)(3) ?*
- Yes
- No
I wish to be register as: (select 1)*
- Non-Profit
- Charity
- Foundation
*
- I agree to Derm.one Affiliate Terms and Conditions
*
- I hereby consent and allow the use of my and/or my company’s information, including sharing with a third party, to assess, detect, prevent or otherwise enable detection and prevention of malicious, invalid or unlawful activity and/or general fraud prevention.

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