PW 9-2024 | New Independent Publisher Application

Independent Publisher Application

Important: All information must be completed in its entirety. I understand that the information provided below will be used to obtain information, and my worthiness may be considered to receive PartnerWeekly Services.
Are You*

Sending Traffic To One of Our Sites DirectlyPosting Full Form Leads to our API
General Applicant Information
Date of application:

MonthDayYear
Contact name:*

First NameLast Name
Title or Position:*
Current physical street address (no P.O. box numbers, please):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is the mailing address the same as your physical address*

YesNo
What is your mailing address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact phone:*
Please enter a valid phone number.
Contact email address:*
example@example.com
Please submit a copy of principal holder/business owner's photo ID, which needs to match the name listed on the W-9/W-8 form.*

Cancelof

Payment Information

If you are submitting a W9 tax form, please provide your SSN below, if you are submitting a W8 tax form, please provide your FTIN below.
SSN or FTIN:*
Please upload a current W-9/W-8 for payment processing.*

Cancelof

Industry Trade References

Please provide the names and contact information of two industry providers that you have worked with in the past or currently work with (i.e. data or lead decisioning providers).
Reference #1
Name:*

First NameLast Name
Title:*
Company:*
Years known:*
Relationship:*
Email address:*
example@example.com
Reference #2
Name:*

First NameLast Name
Title:*
Company:*
Years known:*
Relationship:*
Email address:*
example@example.com

Publisher Agreement

Please read entirely before agreeing to the publisher agreement.
I have read the Publisher Agreement above:*

I agree to the terms & conditions of the Publisher AgreementI have redlines I would like to discuss

Lead Provider Agreement

Please read entirely before agreeing to the Lead Provider agreement.
I have read the Lead Provider Agreement above:*

I agree to the terms & conditions of the Lead Provider AgreementI have redlines I would like to discuss

Advertising & Marketing Guidelines

Please read entirely before agreeing to the Advertising & Marketing Guidelines.
I have read the Advertising & Marketing Guidelines above:*

I agree to the terms & conditions of the Advertising & Marketing GuidelinesI have redlines I would like to discuss

My signature below signifies my understanding and agreement to the terms as stated above and authorizes PartnerWeekly to receive full information as specified above.
Name:*
Title:*
Authorized signature:*

Clear
Date:

MonthDayYear
Today's date
Should be Empty:

Independent Publisher Application