Seabolt
Affiliate Program Application

DESCRIBE YOUR WEB SITE

Site Name (16 characters max):

(The Site Name will be used as the unique identifier of your Affiliate account)

Site URL:

Breifly describe your site:

Briefly describe how you would like to link to Seabolt:

PAYEE

Please enter contact information for the person or company who will be receiving payments from us for this program.

Payee Name:

(Enter the name exactly as it should appear on the check. If the check is to be mailed to someone other than the Payee, enter "Attn:" and the name of the recipient in "Address 1" below.)

Address1:

Address2:

Address3:

City:

State:

Zip:

Phone:

Email:

PAYEE TAX INFORMATION

(U.S. citizens or residents) - Please enter your U.S. social security number (individual) or U.S. Tax ID (corporation) and indicate your status.

SS or Tax ID Number:

Tax Classification:

CONTACT

Please enter contact information for the person responsible for maintaining your website.

 Check box if your Payee and Contact information are identical, and then skip to Payment Method.

Contact Name:

Address1:

Address2:

Address3:

City:

State:

Zip:

Phone:

Email:

Signature

I certify that the above information is true.

Signed:

Name:

Date: