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

Online data:
nom d'utilisateur *: (minimum 6 characters)
Mot de passe *: (minimum 6 characters)
Password (re-type) *: (minimum 6 characters)
Adresse e-mail *:
E-mail (répétition) *:
Homepage *:

Address data:
Nom de la société:
Titre:
Prénom *:
Nom de famille *:
Adresse *:
Code postal *:
Ville *:
Etat/Province:
Pays *:
Téléphone:

Mode de paiement *:
Paypal
     Paypalaccount:
bank transfer
     Account owner:
     Nom de la banque:
     Code de banque:
     Compte:
     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) *