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Affiliate Application

Site Information
Site Name:
URL of Site:

Mailing Address
Address 1:
Address 2:
City:
State:
Province:
Postal Code:
Country:
Phone:         Fax:  

Primary Contact
Name:
Title:
Phone:         Fax:  
E-Mail:

Pay To Address
Same as above
Pay To Name:
Address 1:
Address 2:
City:
State:
Province:
Postal Code:
Country:

Accounting Contact
Same as above
Name:
Title:
Phone:         Fax:  
E-Mail:

Technical Contact
Same as above
Name:
Title:
Phone:         Fax:  
E-Mail:
Pager:

Please provide a preferred username and password for future on-line reporting. Your new password must be between eight and 30 characters, have at least one letter and one number, and be different from your user name:
Requested Username:
Requested Password:
Confirm Password:
   
Important Information
By filling in this section, you will help us determine whether you will be placed in our Affiliate Advertising Network.  Please fill out these questions to the best of your ability.

What is the primary categorical classification of your web site? 

What are the other categorical classifications of your web site?
Auto Entertainment Online Communities
Education News/Information Sports
Government Shopping Finance
Search Engines Travel Personal
Telecommunications/Internet Directories Sweepstakes/Coupons
Corporate Info Family/Lifestyles  


How many unique users visit your web site each month?

How many page views are logged on your web site each month?

What is your business tax classification?

What is your Social Security Number (individual) or Federal Tax ID (corporation)?

What is the date your site was established?


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