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Coupon Partner Program Application

Birthday in a Box can only accept Web-based Affiliates and Coupon Partners.
Please do not complete this application unless you have a website or are currently in the process of building one.
(* = Required Field)


Company Information
*Company Name	*Business Type
*Company Phone Number	*Social Security or Tax ID Number

Contact Information
Prefix	*Address Line 1
*First Name	Address Line 2
Middle Name	*City
*Last Name	*State
*Phone Number		(Scroll Down for Canadian Provinces.)
Fax Number	*Zip Code
*Email Address	*Country
Desired Password

Payment Information
*Make Referral Fee Checks Payable to
Is Your Payment Address the Same as the Address You Entered Above? Yes No

If Your Payment Address Is Different From the Address Above, Please Fill in the Fields Below.
Address Line 1	State
Address Line 2	Zip Code
City

Web Site Information
*Website URL

*Description of Your Website

Characters Left (You May Enter Up to 300 Characters.)

*Year Site Was Established	*Unique Visitors Per Month
*Target Age	*Page Views Per Month
*Target Gender

Feedback
Can We Send You Other Interesting Information Periodically? Yes No
How Did You Hear About Our Coupon Partner Program?

Terms and Conditions
Do You Agree to the Terms of the Coupon Partner Program Agreement ? Yes No
(You need to be able to display a PDF file to read the agreement. If you don't have Adobe Acrobat Reader, go to the Adobe Website to download it.)