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Publishers Inquiry Form

Complete and submit our Online Publisher Agreement below to apply for website representation by Premium Network. Upon review of your application we will contact you.

Contact Information
First Name:
Last Name:
Title:
Company:
Address 1:
Address 2:
City:
State/Province:
Zip Code:
Country:
Phone:
Fax:
Email:
Confirm Email:
About Your Site
Site Name:
URL:
Description:
Category:
About Your Traffic
Unique Visitors - Monthly:    
Unique Visitors - Daily:    
Page Views - Monthly:    
Ad Impressions - Available to PN monthly:    
Data Source:        
Third-party data Source: Date:
Site survey Source: Date:
Estimate        
Ad Sizes available on your site
300x250 728x90 160x600
120x600 468x60
Others:
Audience
Gender:    
Age:    
Household Income:    
Data Source:        
Third-party data Source: Date:
Site survey Source: Date:
Estimate        
Your Content
Is any of your content user generated?:
Are any of your impressions served by auto-refreshing?:
Notes
Online Publisher Agreement
Accept agreement? Yes No Print Agreement
IASH compliant (for UK traffic)
Accept IASH Decline IASH Download PDF version
Create Login Information
User Name:
User Password:
Confirm Password:
Company Information
Entity:   Please print, fill-out and fax W-9 Form to: 415-575-1440
or mail to:
Premium Network, Inc
1663 Mission Street, Suite 560
San Francisco, CA 94103
SSN/Tax ID:
Payment Method
Paypal         Account Email:
Check         Payee on Check:
Submit now to apply. Upon review of your application we will contact you.
Note: Please click on submit button only once, it may take a few moments to process your request.

Premium Network

San Francisco
Premium Network, Inc.
1001 Bayhill Drive, 2nd Floor
San Bruno, California 94066


Phone: 415-575-1444

Fax: 501-642-6376

For more information on:
Web site representation, click here
Advertising on the Premium Network, click here

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