• General
  • Payments
  • Websites
  • Welcome
First Name
Last Name
Company Name
Username
( 4-25 characters )
Password
( 4-25 characters )
Password Again
E-mail
E-mail Again

  • Address
Address 1
Address 2
City
Country
State/Province
Zip/Postal Code

  • Other
Phone Number
Best Day/Time To Call
AIM Username
Y! Username
Affiliates You Currently Work With
Length Of Time In Affiliate Marketing
How Did You Hear About ProLeadsMedia?
Script Used For Your Site
How Do You Prevent/Monitor Fraud?
Industry References
Please provide contact information for 3 industry references. Ie- An affiliate manager of another network you belong to. References WILL be checked! Please include: Name, Network, & Email for each reference. **Failure to complete this section will result in automatic application denial.
Fraud Policy
By checking this box you understand that ProLeadsMedia.com reserves the right to ban any publisher account at any time. Accounts will be banned due to fraud or a high amount of proxy traffic. Pending balances will be sent Net 30 after reversals if your account is closed. *You will be contacted via email if your account is closed.
Paypal Policy
By checking this box you understand that I must use my own (or my spouse's) paypal account to cashout. I can't use a "friend's" paypal account.
Security Code