Webmaster Account
application
Casino Coins Affiliates Program
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Website Information |
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When signing up as a
Casino Coins affiliate, it is essential that the
information you provide is complete and accurate.
Correct information is necessary in order to receive
your commissions and enjoy the full range of benefits
that the Casino Coins Affiliate Program has to
offer!
Sign up today and get on our
payroll!
Fields marked with an asterisk* are
compulsory.
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| Title of
Website:* |
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| Number of
Websites:* |
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| URL address :*
(Provide necessary space,entering each URL on a
separate line, and including http:// at the beginning of
each address) |
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| Category (Select
one)* |
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Personal Home Page |
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Arts |
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Business |
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Education |
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Entertainment |
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Family |
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Health |
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Home & Living |
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Mature/Adult |
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News |
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Regional |
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Science |
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Shopping |
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Society & Culture |
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Sports |
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Technology |
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Travel |
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Women |
| Website Stats |
| Monthly Unique
Visitors: |
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Contact Information
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| Name:* |
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| Title:* |
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| Date of
Birth: * |
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| Phone:* |
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| Email Address:* |
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| Confirm email
Address:*
(We will send your username and password to this
email address. Please type e-mail address twice to
confirm) |
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Please choose a
Username:*
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| Please choose a Password:* |
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Payment Information |
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| Payment Options:* |
Check Wire Transfer |
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Payee Name :*
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Address:*
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| City:* |
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| State/Province:* |
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| Country:* |
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| Postal/Zip Code:* |
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| Telephone Number: |
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Important Information from
you |
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| Please Answer the below
information: |
| Best time to contact you by
phone: |
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| Best method of contact: |
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phoneEmailOther |
| Where did you hear about
us?* |
| From a friend |
| From a banner or advertising |
| From a newsletter |
| Email |
| Other (Please specify) |
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| I would like to receive
casino coins newsletter to advertise |
| Caribbean
Gold |
| English
Harbour |
| Silver
Dollar |
| SuperSlots |
| All Poker
Casino |
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Receiving a weekly newsletter from Casino Coins will
keep you to be up to date with the casino(above)
promotions and learn marketing tips to advertise online
casinos for profit |
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| Yes, I have read and accepted
the Terms and Conditions from Casino Coins.* |
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| Please make sure you have
read the TERMS
AND CONDITION before you click on submit. |
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