Affiliate Sign-up Form

1. We will not sell or distribute any of your contact information without your express, clear consent.

2. Please provide your accurate mailing address. This is where your commission checks will be sent.

3. Please make sure all information is accurate. Email, website(s), and phone numbers will be confirmed before your affiliate application is approved.

Personal Information

Fill out your personal information (fields in bold are required). Why do you need this information?

First Name:
Last Name:
Company:
Checks Payable To:
Email:
Phone:
Address:
Address 2:
City:
State / Province:
Zip / Postal Code:
Country:

Password

Choose a password that will allow you to login to your admin area.

Choose Password:
Confirm Password:

Domains

Enter the domains where you will be linking marketing material from. You can enter either:

an exact path (http://www.domain.com/page.html)
a sub-directory (http://www.domain.com/path/)
or a full domain (http://www.domain.com)

Domain #1:
Domain #2:
Domain #3:
Domain #4:
Domain #5:

Site Categories

Please choose up to three categories that describe your website or websites:

Site Category 1:
Site Category 2:
Site Category 3:

Site Information

Unique Visitors Per Month:
How will you promote our campaigns?
Do You Publish a Newsletter?	Yes No
Number of Subscribers:
Do you send Solo email?	Yes No
Single or Double Optin?	Single Double
Mailing Frequency:
Do you record Time/Date/IP Stamp?	Yes No

Refer a Friend

Enter the email addresses of your friends to let them know about this affiliate program. If they follow the email link here and sign up, they will automatically become part of your second tier! (optional)

Email #1:
Email #2:
Email #3:
Email #4:
Email #5:

I agree to the terms and conditions specified in the Affiliate Agreement

Please add this merchant to my free Kolimbo account to allow for centralized logins and account management.