IMG Affiliate Program

Affiliate Signup Form

Personal Information

Referred By: bosscash77 * Required Fields
First Name *	Enter First Name
Last Name *	Enter Last Name
Company	Enter Company
Address 1 *	Enter Address
Address 2	Enter Address 2
City *	Enter City
State *	Enter State
Country *
Zip Code *	Enter Zip
Phone	Enter Phone
Fax	Enter Fax
Payment Preference *
Tax ID *	Enter a Valid Tax ID

User Account Information

Username *

Password *

Confirm Password *

Email Address *

Paypal Email

AlertPay ID

Membership Fee Amount

29.95

Select Payment Option

This form is for affiliate program enrollment. If you do not wish to participate in the affiliate program, please request the customer link from the affiliate who sent you this enrollment form. ** In order to get PAID, you will need to enter your SS# unless you are NOT a U.S. Resident or Citizen.
*** If not a US Citizen or Resident, you will need to fill out and email the w-8 form provided in the link below in order to get paid.
http://www.insomniamarketinggroup.net/affiliates/fw8ben.pdf

Mail to: teaminsomnia1@gmail.com

I accept and will follow all Terms of Service