PowerLung Affiliate Program Application

Thank you for your interest in becoming a PowerLung Affiliate. Please complete the following application.

Fields marked * are required.

First Name *

Last Name *

Company Name

Email Address *

Phone Number *

PayPal Email Address *

Required to receive payment on commissions.

TAX ID/SSN *

For Applicants Outside of the USA,
please fill the field with 9.

Address *

City *

State/Province

ZIP/Postal Code

Country *

Please provide information regarding the site you want to enroll into the PowerLung Affiliate Program.

Website URL *

I do not have a website.

Year Site Created *

If you do not have a website, please describe how you will use and where you will use the PowerLung Affiliate Program.

Type of Site *

Estimated Monthly Views *

As a part of the PowerLung Affiliate Program, who will you be focusing on for your target audience?

By checking the box below, I confirm that I have read, understand and agree to the PowerLung Affiliate Program Terms and Conditions.*