Affiliate Application

Site Information
Site Name:
URL of Site:
Mailing Address
Address 1:
Address 2:
City:
State:
Province:
Postal Code:
Country:
Phone:	Fax:
Primary Contact
Name:
Title:
Phone:	Fax:
E-Mail:
Pay To Address
	Same as above
Pay To Name:
Address 1:
Address 2:
City:
State:
Province:
Postal Code:
Country:
Accounting Contact
	Same as above
Name:
Title:
Phone:	Fax:
E-Mail:
Technical Contact
	Same as above
Name:
Title:
Phone:	Fax:
E-Mail:
Pager:
Please provide a preferred username and password for future on-line reporting:
Requested Username:
Requested Password:
Confirm Password:

By filling in this section, you will help us determine whether you will be placed in our Affiliate Advertising Network. Please fill out these questions to the best of your ability.

What is the primary categorical classification of your web site?

What are the categorical classifications of your web site?

Arts	Business	Education	Entertainment
Investment Related	Family	Finance	Health
Home Living	Insurance	Mortgage Broker	Mortgage Banker
Mortgage Related	News	Real Estate Agent/Broker	Real Estate Related
Science	Shopping	Sports	Society Culture
Travel	Technology	Women	Personal Home Page
Other

If "Other", please specify:

How many unique users visit your web site each month?

How many page views are logged on your web site each month?

What is your business tax classification?

What is your Social Security Number (individual) or Federal Tax ID (corporation)?

What is the date your site was established?

I have read and agree to the BestRate Affiliate Agreement.
I do not agree to the BestRate Affiliate Agreement.

BestRate.com is an