Thank you for your interest in joining the ClickToBlue network. Please fill out the form below, and we will contact you shortly ('*' denotes required field).

STEP 1: Login Information
*E-Mail:	*Password:           *Confirm: (between 5 - 15 characters)
Password Reminder: [select a question to answer] What's your birthdate (mm/dd/yyyy)? In which city were your born? What was your highschool nick-name?	Answer:
STEP 2: Contact Information
Title *First: MI: *Last: Suffix: Mr. Ms.
*Address:	*City:
*State:	*Zip:
*Phone:	Fax:
STEP 3: Site Information
*Site Name:	*Site URL:
Estimated Traffic (impressions/month): 0-10,000 10,001-25,000 25,001-50,000 50,001-100,000 100,001-150,000 150,001-200,000 200,001-500,000 500,001-1,000,000 1,000,000+	Estimated Unique Users (uniques/month): 0-10,000 10,001-20,000 20,001-30,000 30,001-40,000 40,001-50,000 50,001-100,000 100,001-150,000 150,001-200,000 200,001-500,000 500,001-1,000,000 1,000,000+
Is your audience able to post content? Yes No	How often do you update the site? Daily Bi-Weekly Weekly Bi-Monthly Monthly Seldom
Estimated Primary Audience Age: All Ages Under 18 18-24 24-35 35-54 55+	Estimated Primary Audience Gender: Both Male Female
*Date of Site Launch:	How far "left" does your site lean? Strongly Progressive Progressive Moderate Centrist
*Briefly describe your site: (255 chars max)	*List your issue and/or geographic focus: (255 chars max)
Which ad formats does/will your site support? (Please check all that apply, and select at least one)
468 x 60 - (Full Banner) View 234 x 60 - (Half Banner) View 120 x 60 - (Button 2) View 120 x 90 - (Button 1) View 728 x 90 - (Leaderboard) View 300 x 250 - (Medium Rectangle)View	250 x 250 - (Square Pop-Up) View 160 x 600 - (Wide Skyscraper) View 120 x 600 - (Skyscraper) View Rich Media Text Video
STEP 4: Membership Preferences / Other Info
*Payee Name:	*Social Security / EIN # (for taxes):
Preferred Form of Payment: PayPal Check	Type of Membership: Beta (mon. / 60% share) Gold (3 yr / 60% share) Silver (1 yr / 45% share) Bronze (mon. / 35% share)
If you were referred by another member? No Yes	If so, which publisher?
Will you sell 'direct' through ClickToBlue? Yes No	If so, what is your miniumim CPM (in $)?

By submitting this form, you are agreeing that you have read and accepted the terms and conditions of the Publisher Contract.

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