Partner Sign Up

Contact Information

First Name

Last Name

Legal Entity Type

{{$ctrl.fieldCustomization.company_name_label != '' ? $ctrl.fieldCustomization.company_name_label : 'Company/Individual/Website Name'}}

Website/Social Media http(s)://

Language

Mailing Address

Address Line 1

Address Line 2

City

Zip/Postal Code

Country

State/Province

Phone Number

Billing

Tax ID / VAT or SSN

Payment Method

Reception Method

Phone

Email Address

Paypal Account

First Name

Last Name

Phone

Country

Bank Name

Bank Address

Account Name

Account Number

Routing Number / IBAN

Swift Code

Recipient Name

Bitcoin Address

Paxum ID / Email

First Name

Last Name

Additional Information

Referral Code

Describe the sites and methods used to advertise

Terms and Conditions

Platform Terms

I agree to the platform Terms of Service

Advertiser Terms

I agree to the advertiser Terms of Service

Processing

Thank you for your application to the {{$ctrl.advertiserName}} Partner program.
Your application will be reviewed and you will receive a response in the next 24-48 hours.

Thank you,
{{$ctrl.advertiserName}} Publisher Relations.

Thank you for your application to the {{$ctrl.advertiserName}} Partner program.
A verification email has been sent to {{$ctrl.form.email}}.

You must verify your email before your application can be processed. You will then receive confirmation by email as soon as the request is reviewed.

Thank you,
{{$ctrl.advertiserName}} Publisher Relations.
{{$ctrl.verificationMessage}}