Contact Information
First Name:    * Last Name:    *
Email Address:    *  Confirm Email Address:    *
Address:    * Address 2:   
City:    * Postal/Zip Code:    *
Province/State:    Country:    *
Phone Number:    - * Company Name:    *
Offer URL:    * Offer CPA:    *
Title:    *
Company Background
Are you a subsidiary of another Company:    * If you are a subsidiary, what is your parent company Name:    *
Is your company public or private?:    Number of employees:    *
Website name:   * Company URL:    *
What other business units do you have online? Please list URLs, if more than one: * Who is your target market?:    *
Are you an existing affiliate of seniordiscountclub.com?:    * Which performance-based marketing tactics do you currently employ? Affiliate Marketing
Search Marketing
Lead Generation
Ad Networks *
Please provide a brief description of your business, CPA Offer and Payout: *