Mosaico Diffusion

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	A Travel Agent
	A website
	A hotel
	A Workers' Council / Group
	A Transportation Company

Commercial affiliation

	Affiliation form
	Terms of Affiliation

Web affiliation

	Affiliation form
	Terms of Affiliation

Communication tools

	Summer Festivals Pass presentation
	Banners & Logos
	Info on Events

Mosaico Web Affiliation

Please fill in all the fields on the following form. You just have to click on "Submit" and our Afiliation department will study your request. You will receive an e-mail in the next days to let you know you if your affiliation has been accepted. Any Questions ? business@mosaicodiffusion.com

Mosaico Web Affiliation Form


	Your website

* Name of your website :

* URL of your website :

	Your company :

* Corporate name :

Company Registration Number :

Fiscal status : (company or association)

* Address :

* Postcode :

* Town :

* Country :

* Language :

* E-mail :


	Your Billing :

* Name of the beneficiary of payments :

* Address :

* Postcode :

* Town :

* Country :

* Phone :

Fax :

E-mail :

	Are you submitted to VAT?
	VAT or European VAT number :
	Account Number (IBAN) :
	Bank Code :
	Country of bank branch :


	Additional information

This information helps us know your website better, and enables us to suggest you the tools that best fit your needs

* Kind of website :

Details

other (specify)

	How many visits does your website register each month ?
	* How many unique visitors use your website each month ?
	How many pages are seen on your website each month ?
	On which date did your website go online ? (DD/MM/YYYY)


	Your access to your dedicated section at www.mosaicoworld.com :

* Password requested :
* Password confirmation


	(This password will be reminded in the confirmation e-mail that you will receive)


	Confirmation :

* I certify that the information put on this form are correct
* I hereby declare that I have read the General Terms for Mosaico Web Affiliation by Mosaïco Diffusion, which I accept without any restraint as juridical framework for our partnership.
* I agree that the electronic signature is the proof of my compromise.

Your information are for Mosaïco Diffusion's use only. You have a right to access, modify, rectify and delete your data (art. 34 of french law "Informatique et Libertés" N°78-17 from January 6th 1978). To use this right, please contact us at : Mosaïco Diffusion – Web Affiliations 48 Bvd de Picpus 75012 Paris France

* Required Fields