| Name:________________________________ | ID Number:________________________________ |
| Pay Level:________________________________ (Team Captain or Higher) | |
| Currency Region:__________________________ (examples: Europe, or UK, or NZ) | Currency Type:________________________________ |
| Method of Payment | |
| Wire Transfer ($25.00 cost) | Wire Transfer Form |
| Alert Pay | Account Email Address:__________________________ |
| EcoCard | Account Number:______________________________ |
I have read and agree to the provisions of the International Pay Agent program. I understand that I am required to disburse all payments within 72 hours of receipt of the funds from ClubShop Rewards. I understand that if I fail to honor all the provisions of the Pay Agent program, that I can have my Pay Agent title and privilege removed and should I fail to pay the entitled members their complete entitlement within 15 days, that I can have their entitlements deducted from my commissions and paid on my behalf by ClubShop Rewards. I also understand that my failure to pay my assigned members per their entitlement may result in the termination of my membership. | |
| _________________________ Signature | _________________________ Date |