Publisher Application

Company Information

Company name: *

Address 1: *

Address 2:

City: *

State: *

Postal code: *

Phone: *

Fax:

Contact Information

Name: *

Phone: *

Email: *

Website Information

Do you currently feature Pay-per-Click listings on your site? *

Yes Please select Yes or No

If so, who is is your provider:

What is the primary function and purpose of your website(s)?: *

What are your primary sources of website traffic?: *

What marketing activities are you currently undertaking for your website(s)?:

Describe reasonable, logical ways a user would get to your site:

Please list all URLs that you wish to provide with a publisher solutions product: *

Website Statistics

How many unique users does your website(s) receive per month?: *

How many page impressions does your website(s) receive per month?: *

What is the main revenue stream of your website(s)? (select as many as appropriate) *

Pay-Per-Click

Banner/display advertising

E-commerce

Affiliate programs

Other, please detail: Please choose one or more method of revenue streams for your website(s).

What percentage of your website(s) traffic originate from?:

USA %

Europe %

Other %

How will MIVA AK, Inc. paid listings be integrated within your website(s)?: *

I agree to MIVA AK, Inc. Publisher Center General Terms and Conditions and Publisher Rules and Policies* You must agree to the Publisher Center General Terms and Conditions and Publisher Rules and Policies