Convert2Media

Advertiser Application

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Contact Information

First Name*

Last Name*

Email*

Phone*

AIM or Skype Username

Best Time to Contact*

Preferred Contact Method*

Company Information

Company Name*

Company Title: (ex: CEO, Affiliate Manger, etc)

Company URL*

Street*

City*

State

Country*

Campaign Information

Industry*

Targeted Geographic Region(s)*: Hold down ⌘ or CTRL to select more than one

Exclusive to Convert2Media Affiliates?*: Yes No

When are you looking to launch?*

Do you have experience with Performance-Based Marketing?*: Yes No

How much revenue does your company spend per month through online marketing?*

Highest Current Payout*: $

URL(s) to Landing Page(s)*

Credit Trade References

Name*

Company*

Email*

Fax

Phone*

Name

Company

Email

Fax

Phone

Name

Company

Email

Fax

Phone

Other

Additional Information*