Thank you for your interest in IntactEarnings a division of IntactMedia Inc.For us to expedite the handling of your registration, please complete the questionnaire below. If you are an agency representing a client, click here.

*Denotes required fields.

Salutation
*
First/Given Name
*
Last/Family Name
*

Title

*
Phone *
E-mail (used for login)
*
Password (used for login) *
Retype Password *

Organization Name
*
Street
*
Street 2

City

*
Province / State *
Postal / ZIP code *
Country *
Organization Phone *
Organization Fax

Is your company selling products
or services online today?

YES NO *

What was your company's total online revenue for the last 12 months?

*

What is your company's total number
of full-time employees?

*

What other business units
do you have online?

Please list URLs, if more than one:


If so, are you interested in
setting up an affiliate program
on any of these sites?

YES NO

What is the value of the
average sale on your website?


What is the value of the most
expensive item on your website?

What program are you interested in?
$ PER LEAD % OF SALES BOTH

How much will you pay
on a per-lead basis? ($)


How much will you pay on a
% of sale basis?


(Please remember that a fee of 30% of commission is charged per lead or sale.
Do not include this fee in the above amounts.)


Website Name
*
Website URL
*
Describe your site
*
Monthly Unique Visitors

What is the main
focus of your site?

(Choose up to three categories)

*Personal Home Page
Arts
Auctions
Automotive
Books & Magazines
Business/Office
Charity
Collectibles & Gifts
Communications
Computers & Software
Department Store
Education/Training
Electronics
Entertainment/Games
Fashion
Financial
Flowers & Gardening
Hardware
Health & Beauty
Home & Living
Jewellery
Maternity & Babies
Mature/Adult
Music & Movies
News
Other
Pets & Hobbies
Photography
Real Estate
Regional
Religion & Spiritual
Science
Services
Shopping
Society & Culture
Sports
Technology
Toys
Travel & Recreation
Wedding & Party
Wine & Cigars
Women
*  
Shipping/Serviceable Area(s) *
Currencies accepted on line
*


I ACCEPT*


We thank you for taking the time to complete this form. Please be assured that your information will be held confidential and will be used for IntactEarnings' internal purposes only.

Once this form is submitted, an IntactEarnings agent will contact you shortly.

We look forward to the prospect of developing a relationship together.

Sincerely,
IntactEarnings, a division of IntactMedia Inc.