Please complete and submit this form to become an affiliate with Initforlife.com. All fields below are required unless otherwise indicated.

First Name:
Last Name:
Organization Name:
(optional)
Address line 1:
Address line 2:
(optional)
City:
State/Province/Region:
Zip/Postal Code:
Country:
Email:
Phone (with area code):
Fax (with area code) :
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Website URL:
(http://www.url.com)(optional)
   
Payee Tax Information (for US citizens or residents):
Please enter your US social security number (for individuals) or US tax ID (for corporations).

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Tax Classification:
Pay Commission Checks to:
   
Choose your Affiliate Code.
If you have a web site, your code will automatically be embedded in the HTML code of banner ads. This code can NEVER be changed, so choose one that will serve you PERMANENTLY. You may create a code that promotes your business, but pick one that’s easy to remember, so people will use it! You can include up to 10 characters (numbers, letters or both—NO spaces).

Affiliate Code:
 
Set up an Affiliate Username and Password.
You’ll use these to log into the Affiliate Information Center from Initforlife.com.
Your username cannot exceed 20 characters.

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Affiliate Password:
Verify Password:
 
In case you forget your Username and Password, select a Secret question and enter a Secret answer.
Secret question:
Secret Answer:
 
How did you hear about us?:
   
If you were referred by another Initforlife.com affiliate, please enter that person's Affiliate Code below.
Referring Affiliate's Code: (optional)