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Publisher Application Form

Limited Time Opportunity

Join the Agami Media Publisher Network, make $350 in the first 30 days
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Eligibility Requirements
Fields marked with * are required.


Contact Information
First Name *

Last Name *

Company Name

Phone Number *

Website Information
Primary Website URL *

Average Monthly Unique Site Visitors *

Does your site offer incentives? *

Category 1 *

Category 2

Secondary Website URL

Average Monthly Unique Site Visitors

Does your site offer incentives?

Category 1

Category 2

Add additional websites to this form (up to 5) [x].

Website 3

Website 4

Website 5

Website 6

Website 7

Primary Traffic Origin *

Through what channels are you going to promote our offers? * Use the Ctrl or Shift keys to select more than one channel.

Account Information
Email Address *

Password *

Confirm Password *

Payment Information
Send Payments To *

Country *

ZIP/Postal *

City *

Street Address *

State *

Tax ID / SSN *

State/Province

Province *

Payment Method *

PayPal Email Address *

Payment Threshold *

Email Publishers
Do you own or rent your email list? *

Where do subscribers join the list from? *

Is your email list single or double opt-in? *

How many names do you have in the list? *

General Information
Where did you hear about Agami Media? *

Specify *

What do you think we should do to make your site more profitable?

What types of offers do you search for?

Do you have other comments or suggestions?


I confirm that I have read and agree to the terms of Agami Media Publisher Agreement. *