Affiliate Registration Form

Affiliate Registration Form
Name

First NameLast Name
Address for Mailing Checks

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website Url
Account Email
example@example.com
Promotion Method
Signature

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Date

MonthDayYear
Date
By clicking submit you agree to the terms of this affiliate agreement.
HEALTHandMED.com reserves the right to cancel or modify this agreement at any time. Furthermore, HEALTHandMED.com's system is the final determinant into the usage of affiliate code. If an affiliate coupon code is not utilized for the time of one year, your code and affiliation may be void determined by HEALTHandMED.com and it's team. It is agreed that affiliate will receive a 6% off discount code to provide to their followers. The payout terms is 10% of sales as determined by HEALTHandMED.com and their sales system. This payout will be paid quarterly. If the affiliate code is distributed widely on sales sites that are not your own, the affiliation will be canceled. In addition, if the use of our likeness or affiliation is used in any means detrimental to HEALTHandMED.com, the affiliation is null and void and any moneys due for payout is forfeit.
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