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Publisher Application Form

Eligibility Requirements
Fields marked with * are required.
Contact Information
 
First Name *
Last Name *
Company Name
Phone Number *

Website Information
 
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.
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

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? *

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 *

General Information
 
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?
Where did you hear about Agami Media? *
Specify *

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