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Company Information

Company name: *

Address 1: *

Address 2:

City:

State:

Postal code:

Country: *

Contact Information

Name: *

Email: *

Phone: *

Fax:

Are you focused on monetizing: *

Websites

Domains

Both websites and domains

Total # of domains?:

Website Information

Do you currently feature Pay-per-Click listings on your site?:

Yes

If so, who is/are your provider(s):

What is the primary function and purpose of your website(s)?:

What are you primary sources of website traffic?:

Please list all URLs that you wish to provide a publisher solutions product::

Website Statistics

How many unique users does your website(s) receive per month?:

How many page impressions does your website(s) receive per month?:

What is the main revenue stream of your website(s)?::

How will MIVA AK, Inc. paid listings be integrated within your website(s)?:

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