Referring Affiliate Sign-Up

Who said there's no such thing as a free lunch? You're minutes away from becoming a TimeMD Referring Affiliate!

NOTE: If you are using a Proxy Server we will not be able to validate the CAPTCHA, please Contact Us with all the required fields from this form and we will create your Affiliate account for you.

The * indicates required fields.

Your Information

* First Name
* E-mail Address
NOTE: Valid e-mail address is required for account activation
* Last Name
* Phone #

Contact Information

This is where your checks will be mailed to:
* Address
* City
* Zip
* State

Your Referring Affiliate Login

* Username
Usernames must be at least 6 characters long
* Password
Passwords must be at least 6 characters long
* Confirm Password

Business Information

* Desired Program
Business Name (if applicable)
A Little About Yourself or Business
* Complete the math problem: 2 + 3 = ??
Why ask?: It lets us know your "living" and not a computer.
Agreement Terms and Conditions

  I agree to the Affiliate Agreement Terms and Conditions


Please Contact Us if you do not receive your confirmation email within the next 15 minutes.