<h1 style="text-align: center;">Affiliate Registration</h1>
<div class="icon_box style="><form class="infusion-form" accept-charset="UTF-8" action="https://beliefcloset.infusionsoft.com/app/form/process/3f71c00a94d36f3139b9a849b793215b" method="POST"><input name="inf_form_xid" type="hidden" value="3f71c00a94d36f3139b9a849b793215b" /><input name="inf_form_name" type="hidden" value="CYB Referall Partner Registration" /><input name="infusionsoft_version" type="hidden" value="1.31.0.33" />
<table>
<tr>
<td>
<div class="infusion-field">

<label for="inf_field_FirstName">First Name *</label>

<input id="inf_field_FirstName" class="infusion-field-input-container" name="inf_field_FirstName" type="text" />

</div>
</td>
<td>
<div class="infusion-field">

<label for="inf_field_LastName">Last Name *</label>

<input id="inf_field_LastName" class="infusion-field-input-container" name="inf_field_LastName" type="text" />

</div>
</td>
</tr>
<tr>
<td>
<div class="infusion-field">

<label for="inf_field_Email">Email *</label>

<input id="inf_field_Email" class="infusion-field-input-container" name="inf_field_Email" type="text" />

</div>
</td>
<td>
<div class="infusion-field">

<label for="inf_other_Username">Username *</label>

<input id="inf_other_Username" class="infusion-field-input-container" name="inf_other_Username" type="text" />

</div>
</td>
</tr>
<tr>
<td>
<div class="infusion-field">

<label for="inf_other_Password">Password *</label>

<input id="inf_other_Password" class="infusion-field-input-container" name="inf_other_Password" type="password" />

</div>
</td>
<td>
<div class="infusion-field">

<label for="inf_other_RetypePassword">Confirm Password *</label>

<input id="inf_other_RetypePassword" class="infusion-field-input-container" name="inf_other_RetypePassword" type="password" />

</div>
</td>
</tr>
<tr>
<td colspan="2">
<table>
<tr>
<td><label for="inf_other_NotifyOnLead">Notify on Lead</label></td><td><input id="inf_other_NotifyOnLead_1" name="inf_other_NotifyOnLead" type="radio" value="1" /><label for="inf_other_NotifyOnLead_1">Yes</label></td>
<td><input id="inf_other_NotifyOnLead_0" name="inf_other_NotifyOnLead" type="radio" value="0" /><label for="inf_other_NotifyOnLead_0">No</label></td>
</tr>
<tr>
<td><label for="inf_other_NotifyOnSale">Notify on Sale</label></td><td><input id="inf_other_NotifyOnSale_1" name="inf_other_NotifyOnSale" type="radio" value="1" /><label for="inf_other_NotifyOnSale_1">Yes</label></td>
<td><input id="inf_other_NotifyOnSale_0" name="inf_other_NotifyOnSale" type="radio" value="0" /><label for="inf_other_NotifyOnSale_0">No</label></td>
</tr>
</table>
</td>
</tr>
<tr>

<div class="infusion-field">

<td><input id="inf_option_PleaseMailMyCommissionPaymenttothePaypalEmailAddressBelow" checked="checked" name="inf_option_PleaseMailMyCommissionPaymenttothePaypalEmailAddressBelow" type="checkbox" value="976" style="float:right;" /></td>

<td><label for="inf_option_PleaseMailMyCommissionPaymenttothePaypalEmailAddressBelow">Please Mail My Commission Payment to the Paypal Email Address Below:</label></td>

</div>
</tr>
<tr>
<div class="infusion-field">

<td><label for="inf_custom_PaypalEmailAddress">Paypal Email Address *</label></td>

<td><input id="inf_custom_PaypalEmailAddress" class="infusion-field-input-container" name="inf_custom_PaypalEmailAddress" type="text" /></td>

</div>
</tr>
</table>
<div class="infusion-submit">

<input type="submit" value="Register!" />

</div>
</form></div>