BLAZING BUCKS - registration form

| TERMS | FAQ |

Complete the application below and click "JOIN". Required fields are denoted with an ( * ).
Once your application is approved you will receive a confirmation message that will provide you
with further instructions on how to access your new account.

1. Website Information
Company *
Website URL (Must include http://)

2. Contact Information
Important: You will be required to respond to an email to activate your account so you must use a valid email address.
Email Address *
First name *
Last name *
Telephone Number *
ICQ Number

3. Payment Information

Beneficiary Name *

Address *

City *

State / Province *

Zip Code *

Country *

Tax ID / S.S. #
*If US Resident

**Note: Use your 9 digit Tax ID # without any dashes.

Payment methods:*

Check Epassporte Wire

4. Funds Distribution
Minimum Payout	$

5. Login Information
User name *
Password *
Verify Password *
Note: Use alphanumeric and underscore (_) characters only. Limit: 6-12 characters.