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:

Province:

Postal Code:

Country:

Accounting Contact

Name:

Title:

Phone:

E-Mail:

Technical Contact

Name:

Title:

Phone:

E-Mail:

Pager:

Please provide a preferred username and password for future on-line reporting:

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.

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?