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Fill out the form below to activate your unique tracking number. By submitting this form, you agree to the marketing agreement. You will receive all the information you need as soon as we review your application, generally within a couple of hours!

Please complete all fields, with those with the * next to the field being the most important.

Payment Should Be Payable and Mailed To the following:
BENEFICIARY INFORMATION

BENEFICIARY

ADDRESS

CITY

STATE/PROVINCE

ZIP/POSTAL CODE

COUNTRY

CONTACT INFORMATION

*LAST NAME

*FIRST NAME

TITLE, IF ANY

*E-MAIL

PHONE

FAX

Ensure that the email address you entered above is typed correctly and is fully working. We would prefer it if you did not use a "Free" email account like Yahoo or Hotmail, due to the number of applications we have received with "over quota" Yahoo accounts and "User not known" Hotmail accounts.

HOW DO YOU WANT TO RECEIVE PAYMENT?

	Neteller
	Check (mailed to above address)
	Wire Transfer ($35.00 fee - provide wire instructions in comments area below.

	Please note we only make payments over $50. If under $50 amount will carry forward to next month.

Enter the URL you wish to promote your casino from (if you already have it)

CHOOSE YOUR CASINO PACKAGE OPTION:

*Pick an initial site design from our pre-designed sites

Our support staff will contact you to discuss details of the next steps to take to create your branded casino site. If you chose an extra language for package 2 then please state which language in the comments box below.

Enter any comments or questions you need answering at this stage.

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