Atrinsic Affiliate Network-2

Advertiser Address

Company Name

Address

City

State

Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming

Zip

Contact Information

Contact First Name

Contact Last Name

Email Address

Phone Number

Fax Number

Marketing Details

Date Site Launched (MM/DD/YYYY)

Web site URL

Number of Products on your Website

Is your technical team Inhouse or Outsourced?

In-house Outsourced

Is your creative team Inhouse or Outsourced?

In-house Outsourced

Do you have an existing affiliate program?

• Yes
• No

PPC Details

Do You Participate in PPC/SEM?

• Yes
• No

If Yes, are you working with an internal team or an Agency?

Agency In-house

Would You Like a Sales Person To Contact You About Our PPC Services?

• Yes
• No

SEO Details

Do you currently participate in SEO?

• Yes
• No

If Yes, are you working with an internal team or an Agency?

Agency In-house

Would You Like a Sales Person To Contact You About Our SEO Services?

• Yes
• No

Email Marketing Details

Do you currently participate in Email Marketing?

• Yes
• No

If Yes, are you working with an internal team or an Agency?

Agency In-house

Would You Like a Sales Person To Contact You About Our Email Marketing Services?

• Yes
• No

Tax Classification

Select One

None Individual Partnership Corporation Sole Proprietorship Other Foreign LLC LLP Non-Profit

Tax ID

User Verification

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