fbpx

Affiliate Registration

 

Thanks so much for wanting to be part of my affiliate program and in turn, help people to reduce exposures to harmful chemicals!

Please fill out the form below. Once this is complete, you’ll receive an email with your unique tracking link(s), promotion materials, and commission information.

<form accept-charset="UTF-8" action="https://jq191.infusionsoft.com/app/form/process/f75fb5442b89fd3f739abc6d5851abb3" class="infusion-form" id="inf_form_f75fb5442b89fd3f739abc6d5851abb3" method="POST"><!-- [et_pb_line_break_holder] --> <input name="inf_form_xid" type="hidden" value="f75fb5442b89fd3f739abc6d5851abb3" /><!-- [et_pb_line_break_holder] --> <input name="inf_form_name" type="hidden" value="2nd Tier Affiliates" /><!-- [et_pb_line_break_holder] --> <input name="infusionsoft_version" type="hidden" value="1.69.0.40158" /><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <div> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_field_FirstName" name="inf_field_FirstName" placeholder="First Name *" type="text" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_field_LastName" name="inf_field_LastName" placeholder="Last Name *" type="text" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_field_Email" name="inf_field_Email" placeholder="Email *" type="text" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_field_Phone1" name="inf_field_Phone1" placeholder="Phone *" type="text" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_custom_PaypalEmailAddress" name="inf_custom_PaypalEmailAddress" placeholder="Paypal Email Address *" type="text" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_field_Website" name="inf_field_Website" placeholder="Website" type="text" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <div> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <div class="text"><!-- [et_pb_line_break_holder] --> <div class="text" contentid="paragraph"><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <p><!-- [et_pb_line_break_holder] --> <strong><!-- [et_pb_line_break_holder] --> <span>Set up your login details for the Affiliate Center. </span><!-- [et_pb_line_break_holder] --> </strong><!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <p><!-- [et_pb_line_break_holder] --> <em><!-- [et_pb_line_break_holder] --> <span>Note: your username will be part of your unique tracking link, so make it appropriate!</span><!-- [et_pb_line_break_holder] --> </em><!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_other_Username" name="inf_other_Username" placeholder="Username *" type="text" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_other_Password" name="inf_other_Password" placeholder="Password *" type="password" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <input class="infusion-field-input" id="inf_other_RetypePassword" name="inf_other_RetypePassword" placeholder="Confirm Password *" type="password" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <label for="inf_other_NotifyOnLead">Notify when referral becomes a lead?</label><!-- [et_pb_line_break_holder] --> <div class="infusion-radio"><!-- [et_pb_line_break_holder] --> <div class="options-container"><!-- [et_pb_line_break_holder] --> <span class="infusion-option"><!-- [et_pb_line_break_holder] --> <input id="inf_other_NotifyOnLead_1" name="inf_other_NotifyOnLead" type="radio" value="1" /><!-- [et_pb_line_break_holder] --> <label for="inf_other_NotifyOnLead_1">Yes</label><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <span class="infusion-option"><!-- [et_pb_line_break_holder] --> <input id="inf_other_NotifyOnLead_0" name="inf_other_NotifyOnLead" type="radio" value="0" /><!-- [et_pb_line_break_holder] --> <label for="inf_other_NotifyOnLead_0">No</label><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-field"><!-- [et_pb_line_break_holder] --> <label for="inf_other_NotifyOnSale">Notify When Referral Becomes A Sale?</label><!-- [et_pb_line_break_holder] --> <div class="infusion-radio"><!-- [et_pb_line_break_holder] --> <div class="options-container"><!-- [et_pb_line_break_holder] --> <span class="infusion-option"><!-- [et_pb_line_break_holder] --> <input id="inf_other_NotifyOnSale_1" name="inf_other_NotifyOnSale" type="radio" value="1" /><!-- [et_pb_line_break_holder] --> <label for="inf_other_NotifyOnSale_1">Yes</label><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <span class="infusion-option"><!-- [et_pb_line_break_holder] --> <input id="inf_other_NotifyOnSale_0" name="inf_other_NotifyOnSale" type="radio" value="0" /><!-- [et_pb_line_break_holder] --> <label for="inf_other_NotifyOnSale_0">No</label><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <div> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="infusion-submit"><!-- [et_pb_line_break_holder] --> <button class="infusion-recaptcha" id="recaptcha_f75fb5442b89fd3f739abc6d5851abb3" type="submit">Sign Up!</button><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></form><!-- [et_pb_line_break_holder] --><script type="text/javascript" src="https://jq191.infusionsoft.com/app/webTracking/getTrackingCode"></script><!-- [et_pb_line_break_holder] --><script type="text/javascript" src="https://jq191.infusionsoft.com/resources/external/recaptcha/production/recaptcha.js?b=1.69.0.40158-hf-201804171813"></script><!-- [et_pb_line_break_holder] --><script src="https://www.google.com/recaptcha/api.js?onload=onloadInfusionRecaptchaCallback&render=explicit" async="async" defer="defer"></script><!-- [et_pb_line_break_holder] --><script type="text/javascript" src="https://jq191.infusionsoft.com/app/timezone/timezoneInputJs?xid=f75fb5442b89fd3f739abc6d5851abb3"></script><!-- [et_pb_line_break_holder] -->

Top 10 Toxins

Practitioner Checklist!

We'll never share your information, or spam you, ever!

LEARN ABOUT THE TOP 10 TOXINS THAT ARE UNDERMINING YOUR CLIENT'S HEALTH

Join My Newsletter!

We'll never share your information, or spam you, ever!

Stay in the loop with current news about environemtnal toxins, safer product recommendations, and more!