Dear Affiliate,

Please complete the following form accurately and completely to have your earnings electronically transferred to your bank account. Please allow us 7-10 business days to verify your information and setup of your Direct Deposit. If you have any questions, please contact the Affiliate Program Administrator at +1 (888) 641-3075.

Your First Name: (required)

Your Last Name: (required)

Your Address: (required)

Your City: (required)

Your State: (required)

Your Zip: (required)

Your Email: (required)

Your Phone: (required)

Your Bank Name: (required)

Your Bank Type: (required)

Your Bank City: (required)

Your Bank State: (required)

Your Bank Phone: (required)

Your Account Type: (required)

Your Account Routing Number: (required)

Your Account Number: (required)

Last Four Of Your SSN: (required)

xxx-xx-

As an Affiliate of CitySpotz Media Corp, I hereby authorize the direct deposit of my commissions into the above mentioned bank account.