Partner Registration Form

Registration Process

1. Download, Read and sign Confidentiality Agreement. (Download Here)
2. Fill the below registration form.
3. Send a copy of a government-issued ID (passport, driver’s license, or national ID) to partner@llcig.com or Whatsapp: +989023100114

Partner Registration Form

Basic Information

Full Name *

This field is required.

Nationality *

This field is required.

Date of Birth *

This field is required.

Country of Residence *

This field is required.

Contact Details

Email *

This field is required.

Preferred Contact Method *

Select ItemWhatsAppTelegramEmail

This field is required.

Phone Number (with Country Code) *

This field is required.

Language Proficiency

Native Language *

This field is required.

Other Languages

Are you fluent in English? *

Yes

No

This field is required.

Professional/Referral Background

Occupation (Optional)

Other Languages

How did you hear about the Limb-Lengthening Referral Program?

Select ItemSocial MediaWebsiteFriend/ColleagueOther

Affiliation/Organization Name (If applicable)

Referral Plan

How do you plan to refer patients? *

This field is required.

Estimate the number of patients you can refer monthly *

Select Item1-34-67-910-12

This field is required.

Banking and Payment Information

Preferred Payment Method *

Select ItemBank TransferDigital CurrenciesCash

This field is required.

Bank Details (for transfer)

Bank Name

Account Name

Account Number

SWIFT Code

Digital Currency (for transfer)

Preferred Digital Currency

Select ItemTetherTRONBitcoinEthereum

Wallet Address

Terms and Agreement

Confidentiality Agreement *

I agree to keep all patient information confidential and to comply with the program’s ethical promotion guidelines.

This field is required.

Marketing Standards *

I agree to promote the limb-lengthening services only using materials and information provided by the program.

This field is required.

Acknowledgment *

I have read and agree to the terms outlined in the Confidentiality Agreement.

This field is required.

Verification Documents

Please send a copy of a government-issued ID (passport, driver’s license, or national ID) to partner@llcig.com or Whatsapp: +989023100114

Additional Information (Optional)

Declaration and Consent

*

I confirm that the information provided is accurate to the best of my knowledge.

This field is required.

Submit