Affiliate Registration form

Full Registered company/business name:	*
Registered/Principal Business Address	*
	*
Postcode	*
Registered company number	*
Phone number	*
Fax number
Contact name	*
Email address	*
Web address	*
Nature of Business	*
How did you hear about us?	Please Select Search Engine Press Release Advertisement Recommendation Exhibition
Other
Which Micro Sites do you wish to link to?
Mortgage Payment Protection Insurance - Ongoing commission - 15% of monthly premium
Income Protection Insurance - Ongoing commission - 15% of monthly premium
Amateur Sports Insurance - Ongoing commission - 25% of monthly premium
Medical Cash Plans - Ongoing commission - 20% of monthly premium
Motorcyclist Personal Accident Cover - Ongoing commission - 10% of monthly premium
Pet Healthcare - Indemnity commission - £10 per sale
Bank Details (for commission purposes)
Bank name	*
Bank address	*
	*
Bank Postcode
Bank account number	*
Bank sort code	*
Bank account name	*
Please select your FSA Status
Non Authorised
Directly Authorised
Appointed representative of a directly authorised company
If you are directly authorised by the FSA, please enter your FSA number
If you are an appointed representative of a company who are directly authorised by the FSA, please enter their details below.
Company Name
Company Address
FSA Number
Any Further Comments
	* shows the required fields.