Affiliate Membership Application

When you are finished filling out the form, click on the "Submit" button.

*Indicates required fields.

*Company Name

*Site Title

*Web Site URL, ex: http://www.yourcompany.com

*Address Line 1

Address Line 2

*City

*State

*Zip Code

Business Type

Business Classification

Primary Contact Name
Salutation (optional)

*First Name

Middle Initial (optional)

*Last Name

Phone Number

*E-mail Address


Does your web site require a login? Yes No

Does your web site donate a portion of its proceeds to
charitable organizations and/or educational institutions? Yes No

*Please tell us why you feel your vision matches ours and how partnering
with each other could be empowering for both of us.


Use the following check boxes to convey extra information about your organization.

Baby & Maternity
Books & Magazines
Designer & Luxury
Electronics & Camera
Flowers & Gifts
Food & Beverage
Health & Personal Care
Home & Garden
Home Office
Pets
Sports & Outdoors
Travel
Toys & Games
Telecom
Apparel, Shoes & Accessories
Automotive & Boating
Bargains
Beauty

Energy Medicine
Men

DVDs & Videos
Education
Alternative Health
Finance
Insurance
Media & Communications
Music & Entertainment
Jewelry & Watches
Computers & Software
Arts, Antiques & Collectibles
African-American
Business-To-Business
Finance (Credit Cards)
Finance (Insurance)
Finance (Loans)
Free Stuff
Latino
Teen
Women

Other

Yes! I have read about and am in alignment with the Cancer Free Society Dream.

Yes! I have read the Guiding Principles of the Cancer Free Society and am in alignment with them, as well.

Yes! I am applying for Affiliate Membership into the Cancer Free Society. Please contact me to discuss further details.


 
 

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