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PromoPayment Referral Contest
Your Contact Information
Your Name:
*
Email:
*
Phone:
*
Your Referral’s Contact Information
(Please fill out as much as possible)
First Name:
*
Last Name:
*
Organization:
*
Email:
*
Phone:
*
Country:
Select one:
USA
Canada
UK
Australia
NewZealand
Other
Full Street Address:
*
City:
*
State:
Select One
[insert_php] $selected_state = ”; if(isset($_SESSION[“state”])) $selected_state = $_SESSION[“state”]; include(TEMPLATEPATH. ‘/arrays.php’ ); foreach($states as $abbrev=>$state) { $selected_attribute = ”; if($selected_state==$abbrev) { $selected_attribute = ‘ selected=”selected”‘; } echo “
$state
“; };[/insert_php]
Province:
Select One
[insert_php] $selected_province = ”; if(isset($_SESSION[“state”])) $selected_province = $_SESSION[“state”]; include(TEMPLATEPATH. ‘/arrays.php’ ); foreach($provinces as $abbrev=>$province) { $selected_attribute = ”; if($selected_province==$abbrev) { $selected_attribute = ‘ selected=”selected”‘; } echo “
$province
“; };[/insert_php]
[insert_php] if ($_SESSION[“country”] == “UK”) { echo ”
Zip/Postal Code:
*
“;} else { echo “
Zip/Postal Code:
*
“;} [/insert_php]
ASI#:
Do you currently have a credit card merchant account:
*
Yes
No
Current Monthly Volume:
Select one:
Under $4,999
$5K-$9,999
$10K-$24,999
$25K-$49,999
$50K-$99,999
$100K+
ASI Products Used:
SmartBooks
ProfitMaker (Integration requires add-in component)
Comments/Questions:
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