AFFILIATION FORM  
  Account Information  
  Company Name (If no Company Name, leave blank)
  Address 1 *  
  First Name *  
  Address 2  
  Last Name *  
  City *  
  Email Address *  
  State/Province *  
  User Name *  
  Country *  
  ZIP/Postal Code *  
  Password *  
  Confirm Password *  
  IM  
  Phone Number * Use numbers only - no spaces or dashes
       
  Payment Information  
  Tax ID *  
  EIN#  
  SSN# Use numbers only - no spaces or dashes
  Tax Class *  
  Make Payment To*  
  All US Affiliates: We must have a W9 on file to make your commission payments as per federal law. Please download the form here, complete,
sign and fax to: (949) 258-8636
  Marketing Information  
  Describe Your Business *  
  Marketing Methods
  Email *  
  Co-registration *  
  Mobile *  
  Incentives *  
  Search *  
  List Management *  
  Website *  
  Pop-up/Unders *  
  Add Site  
 
You certify under penalty of perjury that the information entered into your application is legally accurate.