Affinity Mall Membership Application Form

Note: Items in RED are required for proper processing of your application.

Member Profile

Last Name: , First Name:
Company or Organization:

Street Address:
City: , State: , Zip Code:

E-mail: , Telephone:

In the space below, briefly respond to the following : (1) please tell us a little about you, your company or organization; (2) why you would like to become a member; and (3) how you intend to use and promote your Affinity Mall:

To what name should we make your commission checks payable?

Social Security # or Tax ID # for check recipient:
(This info. is needed for accounting & tax purposes. No payments can be made if this information is not accurate.)

Membership Package Desired

Which membership package would you like to request?
Basic Membership (more info.)
Standard Private-Label Membership (more info.)
Premium Private-Label Membership (more info.)

Website Information (if applicable)

Home URL:

(such as http://www.website.com)
Provide a URL for your "Home" web site. A link to this URL may be provided on your Affinity Mall.

Unique Visitors Per Month: How many unique visitors does your website have each month?

Website Categories:

*Personal Home Page
Arts
Business

Education
Entertainment
Family

Health
Home & Living
Mature/Adult

News
Regional
Science

Shopping
Society & Culture
Sports

Technology
Travel
Children

What audience does your website appeal to? Choose all that apply.

Image URL:

(such as http://www.website.com/image.gif; must be in GIF OR JPEG format only and size must be 275x30)
Provide a URL for the image (usually the name or logo of your web site or company) which you would like to appear on your Affinity Mall.
As an alternative, you may also submit your image by e-mailing it, as an attachement, along with your Affinity Mall Name and Login ID to members@YourDigitalMall.com

(Only for Standard or Premium Private-Label Membership). If no image is provided, your Affinity Mall's Name will be displayed instead of this image.

Home Page Greeting or Comment:

(250 characters max.) Provide a short greeting or comment that will appear on the Welcome Page of your Affinity Mall. If you'd like, you can use HTML tags to spice up your description. (Only for Standard or Premium Private-Label Membership)

Affinity Mall Access Information

Desired Affinity Mall Name:

(e.g., "ACME's Online Mall") Name will appear on your Affinity Mall and for listing purposed such as in the Affinity Mall Directory.

Desired Login ID:

(20 characters max., lowercase letters only)
Login ID is used to access your account (to view reports, update profile, etc.) and will appear on your Affinity Mall. Login ID cannot be changed!

Choose a password:

(6-20 characters, case sensitive, no spaces.)
Remember your login ID & password! You need them to log in!

Re-type password:
(6-20 characters, case sensitive, no spaces.)

Additional Information

How did you hear about YourDigitalMall.com?

Promotional Code, in any:
Agent Code, if any:

Please use the space below for any other comments, suggestions, or feedback you may have:

By pressing the "I AGREE" button below, you indicate that (1) you want to apply to participate in The Affinity Mall Program at YourDigitalMall.com; (2) that you have reviewed the Affinity Mall Membership Agreement and understand its contents; (3) if Positive Realities Multimedia, LLC, owner and publisher of YourDigitalMall.com, accepts this application, you agree to be bound by the terms and conditions of the membership agreement.
Please only click once on one of the buttons below.
It may take a few seconds for your application to be submitted.