Affiliate Form



Online Affiliates drive trafic to the Optima Website Services ® platform via their own website or through internet marketing.	Offline Affiliates refer clints to the Optima Website Sevices ® platform using traditional (non-online) media channels.

Please note: any affiliate who chooses their account type as Online Affiliate and is found to be actually Offline will immediately be switched Off.

* First Name:
* Last Name:
Company Name:
* Country:
* Street Address:
* City:
State/Province:
Zip/Postal Code:
* Email Address:
* Verify Email:
Instant Messenger Type:
Instant Messenger Id:
* Phone Number 1:
Phone Number 2:
Please ensure that the telephone number you listed above is correct and contains your country code and area code, otherwise we will not be able to contact you regarding your account and commission payments.
* Website Address:
Payment Details: If you do not have this information at the moment, you may enter it later.
Please select:	Paypal Account: Bank Wire:
Paypal Account:
Bank Name:
Branch Name:
Street Address:
City:
Country:
Account Holders Name:
Please note this must be identical to the first and last name you have entered above. If you wish to be paid to your company’s bank account, we will require a receipt for each payment.
Account Number:
SWIFT / Sort code:
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