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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)
Indirizzo email *:
Ripeti email *:
Homepage *:

Address data:
Ragione sociale:
Titolo:
Nome *:
Cognome *:
Indirizzo *:
C.A.P. *:
Città *:
State/Province:
Paese *:
Telefono:

Payment method *:
Paypal
     Paypalaccount:
bank transfer
     Account owner:
     Nome della banca:
     Codice banca:
     Numero di conto :
     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) *