| Please complete and submit the following Affiliate Registration form. Applicants will be contacted by a My Therapy Networlk Account Executive within 3 business days. Please refer to our Affiiliate Agreement for additional details.
Step 1: Site Information
Website Name:
URL (http://):
Do you have an e-mail newsletter?
E-newsletter Name:
Category:
(choose the category that best fits your site)
Describe your site and/or newsletter (25 words or less) :
Step 2: Contact Information
Your Name:
Your Title:
Phone:
E-mail:
Step 3: Company Information
Organization Name:
Your Name (if no organization)
Address:
Address2:
City: State:
Zip:
Country:
Organization Phone Number:
Organization Fax Number:
SSN/EIN or SSN:
Other comments or questions:
Do you have friends or associates who have Web sites or email newsletters that would benefit from the MyTherapyNetwork.com affiliate program? If so, please E-Mail us with their contact information.
Yes, I have read through the Agreement and completed the affiliate Program Application form above. (Please read the Affiiliate Agreement now, if you have not done so.) I understand someone will contact me regarding my site's acceptance to the program and provide me with the necessary banners and buttons to link to MyTherapyNetwork.com
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