Splash-X Designs

Personal Information

Fill out your personal information (fields in bold are required). Why do you need this information?

The information gathered here is used to determine whether or not a site qualifies for the program, and to verify that the person applying is associated with the site they are applying with. Before you become an affiliate, we will only contact you to determine your qualification to be included in the program. After you join, you will receive program-related material as needed via email or phone. Physical address information is required so that we can mail commission checks.

First Name:	*
Last Name:	*
Company:	*
Checks Payable To:	*
Email:	* *
Phone:	*
Address:	*
Address 2:
City:	*
State / Province:	*
Zip / Postal Code:	*
Country:	*

Password

Choose a password that will allow you to login to your admin area.

Choose Password:	*
Confirm Password:	*

Domains

Enter the domains where you will be linking marketing material from. You can enter either:

an exact path (http://www.domain.com/page.html)
a sub-directory (http://www.domain.com/path/)
or a full domain (http://www.domain.com)

Domain #1:	* * *
Domain #2:	* *
Domain #3:	* *
Domain #4:	* *
Domain #5:	* *

Site Categories

Please choose up to three categories that describe your website or websites:

Site Category 1:	*
Site Category 2:	*
Site Category 3:	*

Site Information

Unique Visitors Per Month:	* *
How will you promote our campaigns?	*
Do You Publish a Newsletter?	Yes No
Number of Subscribers:	* *
Do you send Solo email?	Yes No
Single or Double Optin?	Single Double
Mailing Frequency:	*
Do you record Time/Date/IP Stamp?	Yes No

Refer a Friend

Enter the email addresses of your friends to let them know about this affiliate program. If they follow the email link here and sign up, they will automatically become part of your second tier! (optional)

Email #1:	*
Email #2:	*
Email #3:	*
Email #4:	*
Email #5:	*

I agree to the terms and conditions specified in the Affiliate Agreement

Please add this merchant to my free Kolimbo account to allow for centralized logins and account management.