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Registration for LaserSoft Imaging Affiliates Program
(The input fields marked in red have to be filled.)

Online data:
Username *: (minimum 6 characters)
Password *: (minimum 6 characters)
Password (re-type) *: (minimum 6 characters)
Email address *:
Email (re-type) *:
Homepage *:

Address data:
Company Name:
Title:
First Name *:
Last Name *:
Billing Address *:
ZIP / Postal Code *:
City *:
State/Province:
Country *:
Phone:

Payment method *:
Paypal
     Paypalaccount:
bank transfer
     Account owner:
     Bank name:
     Bank routing nr:
     Account:
     S.W.I.F.T-Code:
     IBAN:
check

I have read the terms of LaserSoft Imaging Affiliates Program and agree to them. (Read the agreement) *