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Last Name: *

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Company Name:

Address: *

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Country: *

E-Mail Address: *

Phone Number:

Fax Number:

Billing Information

Payment Choice: *

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Please choose your preferred form of pay out. In case of Wired Payments we do not pay out under $100.- (USD) monthly proceeds. You can also choose to go for both forms of pay out. In this case please let us know your preference in the comments field.

PayPal

PayPal Address:

If you prefer to be paid via PayPal then please fill in your PayPal E-Mail address

Wire Payment Details

Account holder name:

Account holder address:

Account holder country:

Account number or IBAN:

Your bank account number or IBAN (International Bank Account Number).

Routing / ABA / Fedwire:

Please provide the Routing / ABA / Fedwire details if available.

BIC / SWIFT code:

Bank Identifier Code or SWIFT Code.

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Comments:

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I accept the Terms and Conditions of BannerConnect.

E-mail:	publishers@bannerconnect.net
Call:	+31 (0)46 7074992
Fax:	+31 (0)46 4517688

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