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You must agree with the rules described at the following page. Failure to adhere to these rules will cause immediate deletion from our program and you will lose all monies owed.

You must supply us with the URLs that you will be advertising the dialer on. We regularly check sites for advertising accuracy and rule violations.

We reserve the right to deny any site from using this program for any reason.

* - indicates a required field.

* Contact Name:
* Check Payable To:
* Company:
* Address:
* City:
* State:
* Zip or Postal Code
* Country:
Phone Number:
Fax Number:
* Email Address:
Social Security Number:
REQUIRED FOR US CUSTOMERS ONLY
Method of Payment: Check by Regular Mail (FREE)
Check by FedEx ($11.95)
Wire Transfer ($40)

(Enter Wiring Info Below)
Bank Name:
Bank Address:
Account Name:
Account Numbers:
Routing Numbers:
* Site(s) Advertising Dialer:


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