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)


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