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AFFILIATE REGISTRATION

Please take a moment to fill out this brief application. Thank you for becoming an OldDebts.com affiliate.

Before finalizing and submitting your application, please review our Terms and Conditions, which describes the terms and conditions of your affiliation with the OldDebts Affiliate Program.

Once you have filled out this form and reviewed the agreement, press the "I Accept" button to indicate your acceptance of the agreement and to submit your application. We will send an email confirming your acceptance in the program. The email will include further instructions describing how to begin participating in the program.

Primary Contact & Mailing Address

Name: *

Title:

Company Name: *

Address 1: *

Address 2:

City: *

State: *

Postal/ZIP Code: *

Country:

Phone: *

Fax:

Email: *

Pay To Address *

Check box if same as primary contact information

Pay To Name: *

Address 1: *

Address 2:

City: *

State: *

Postal/ZIP Code: *

Country: *

Please provide a preferred username and password for future on-line reporting:

Desired Username: *

Max 8 Characters

Desired Password: *

Max 8 Characters

Confirm Password: *

Max 8 Characters

Your Site Information

Site Name:

Please list your website address(es). If you have more than 4 addresses, list your most popular ones.

Primary URL:

http://

Secondary URL:

http://

Secondary URL:

http://

Secondary URL:

http://

Additional Information

Please classify your primary website:

If "Other", please specify:

How many unique users visit your primary website each month? (Estimates are okay)

How many page views are logged on your primary website each month? (Estimates are okay)

What is your business tax classification?

If you are a corporation, what is your Federal Tax ID:

How did you hear about our affiliate program?

I agree to the terms of our Terms and Conditions.*

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