Affiliate Application

Please fill out the following form in as much detail as possible so that we can process your affiliate application as soon as possible.

Your Name & Address

Title *

First Name *

Last Name *

Your Email Address *

Website Address

Company Name

Street Address 1 *

Street Address 2

Town *

State *

Post Code / Zip Code *

Country *

Your Contact Numbers

Note: Please include your country and area code in front of your home phone number. (If you know them)
No other characters, just numbers please.

Phone Number Type*

Phone Number *

Other Phone Number Type

Other Phone Number

Fax Number Type

Fax Number

Your Marketing Information

Which applies to you? *

If a Health Practitioner, what is
your field of work?

If ‘Other’ please specify

How did you find out us? *

If ‘Other’ or ‘Word of Mouth’ please specify

Please tell us about your businessand how you plan to romote our products and services. *

Login & Commission Payment Information

Create Your Affiliate Code *

Your code must start with a letter. Your code will be shown in your affiliate (web/email) link.
Eg. https://dm01.infusionsoft.com/go/YourCode

Your Affiliate Login Password *

Retype Login Password *

Bank Details (Australia Only)

Bank Name

Bank BSB (123-456)

Bank Account Name

Bank Account Number

Paypal Email
(Outside Australia Only)

Get a free Paypal account here

I agree with the terms of service

* Mandatory information

Providing this information constitutes your permission for Universal Source P/L and Vita Eterna P/L
(Forensic Healing & Tri-Vortex) to contact you regarding related information via mail, email, fax and phone. Please note: We will NEVER sell, rent, exchange, trade or disclose your details to any company or individual.