Affiliate Registration First Name Last Name Email Address Phone Number Company Name Company Website (Optional) Street Address City State/Province ZIP/Postal Code Country Primary Website URL (where you’ll promote Extreme Motus) Other Promotional Channels Blog/Website Social Media Email Newsletter YouTube/Video Content Paid Ads (Google, Meta, etc.) Unlisted Promotional Platforms How did you hear about our Affiliate Program? Do you have experience promoting mobility products or adaptive equipment? Yes No Referral Code Confirm Password Password Become an Affiliate
