Dear Affiliate,

Please complete the following form accurately and completely to have your monthly earnings electronically transferred to your PayPal account. Please allow us 3-5 business days to verify your information and setup of your transfer. If you have any questions, please contact the Affiliate Program Administrator +1 (888) 641-3075.

If you do not have a PayPal account but would like to establish one, click here. After completing the registration, return to this form and complete the process.

Your First Name: (required)

Your Last Name: (required)

Your PayPal Email: (required)

Your Phone: (required)

Your Account Number: (required)

Last Four Of Your SSN: (required)

xxx-xx-

As an Affiliate of CitySpotz Media Corp, I hereby authorize the transfer of my commissions into the above mentioned PayPal account.