Extatica Affiliate Application

Referral Partner Enrollment Form

*Subject to Approval

Your Personal Information

First Name *
Last Name *

Email *

Phone *

Your Company Information

Company Name *

Type of Business

Sole Proprietorship or PartnershipLLC or S-Corp C-Corp

Your Website: *

Other Websites Where You Will Promote Our Products or Services:

How Do You Plan to Promote Our Programs and Services? *

Email List Size *

Facebook Url:

Twitter:

Other Social Media:

Tax ID - Required of All U.S. Based Companies

Paypal Email *

Mailing Address *
City *
State *
Postal Code *
Country *

Your Affiliate Identification Information

Note: Your Username is also your affiliate identification marker that will be included in your affiliate referral link. It should be 3 - 7 characters in length.

Username *

Password *

Confirm Password *

Clicking the purple "Sign Me Up!" button indicates you Accept our Affiliate Terms and Conditions.