First Name

Last Name

Email Address

Company Name

Company Website

Primary Contact Name

Primary Contact Email

Customer Service Email Address

Do you belong to an affiliate network?
—Please choose an option—ShareASaleLinkshare/RakutenCommision JunctionAvant LinkCactus Mediaebay/PepperJamImpact RadiusNo Affiliate Network/Other

Primary category you sell in
—Please choose an option—ElectronicsEntertainmentFood & DrinkGiftsHealth & BeautyHomeJewelry & WatchesKids & BabyMenOffice & EducationPatio, Lawn & GardenPetsShoesSports, Fitness & CampingTools & DIY SuppliesTravelWomenOther

Are you based in the United States?
YesNo

Can you offer exclusives to Puredot Deals?
YesNo

Primary partnership goal?
Increase Sales VolumeReactivate Old UsersGet New UsersOther

Additional Info (Optional)

How did you hear about us? (Optional)

Referral Code (If Applicable)

I understand a $35 fee will be charged upon approval of application.