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<div class="ContentHeader">Convertirte en un Distribuidor</div>

<div class="MainText">Si te gustar&iacute;a convertirte en un distribuidor de RegaloCard y ofrecer los servicios de RegaloCard en tu tienda, sitio web, o en alguna otra localidad por favor llena el siguiente formulario y ser&aacute;s contactado por un representante de RegaloCard.</div>
<div class="MainText">
	<form id="form1" name="AffilForm" method="post" action="afiliates.asp">
	<table width="450" border="0" cellpadding="0" cellspacing="0">
		<tr>
			<td width="284" align="left">Nombre</td>
			<td width="166" align="left"><input type="text" name="Name" /></td>
		</tr>
		<tr>
			<td align="left" nowrap="nowrap">Correo Electronico</td>
			<td align="left" nowrap="nowrap"><input type="text" name="Email" /></td>
		</tr>
		<tr>
			<td align="left" nowrap="nowrap">Pais</td>
			<td align="left" nowrap="nowrap">
				<select name="Country">
					<option selected="selected">USA</option>
					<option>Canada</option>
					<option>Mexico</option>
					<option>Guatemala</option>
					<option>El Salvador</option>
					<option>Honduras</option>
				</select>
			</td>
		</tr>
		<tr>
			<td align="left" nowrap="nowrap">Telefono</td>
			<td align="left" nowrap="nowrap"><input name="Phone1" type="text" size="3" /> <input type="text" name="Phone2" /></td>
		</tr>
		<tr>
			<td align="left" nowrap="nowrap">Distribuye algun servicio?</td>
			<td align="left" nowrap="nowrap">
				<select name="DistributeService">
					<option>Si</option>
					<option>No</option>
				</select>
			</td>
		</tr>
		<tr>
			<td align="left" nowrap="nowrap">Que tipo de servicios distribuye?</td>
			<td align="left" nowrap="nowrap"><input type="text" name="ServiceTypes" /></td>
		</tr>
		<tr>
			<td align="left" nowrap="nowrap">En que zona o areas geografica distribuyes?</td>
			<td align="left" nowrap="nowrap"><input type="text" name="Geographical" /></td>
		</tr>
		<tr>
			<td align="left" nowrap="nowrap">Promedio de ventas mensuales</td>
			<td align="left" nowrap="nowrap">
				<select name="Sales" size="1">
					<option>$0.00 - $4,999</option>
					<option>$5,000 - $9,999</option>
					<option>$10,000 - $24,999</option>
					<option>$25,000 - $39,999</option>
					<option>$40,000 - $49,000</option>
					<option>Mas de $50,000</option>
				</select>
			</td>
		</tr>
		<tr>
			<td height="36" colspan="2" align="center" nowrap="nowrap">
				<input type="submit" name="Submit" value="Enviar" />
				<input type="submit" name="Submit2" value="Borrar" />
			</td>
		</tr>
	</table>
	</form>
</div>

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