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Please print this form and return.
E-mail: affiliates@ampedmedia.com | Fax: 321-951-2510
Amped Media Bank Wire is a fast and easy way to receive your affiliate commissions directly to your personal bank account. With this feature there is no waiting for checks to be mailed or excessive clearing or hold times. To activate Bank Wire, please complete the following form and consent to the below listed agreement.
Personal Information
To ensure this form is routed properly, please complete all the spaces listed below to the best of your ability. Failure to provide certain information may lead to a denial or delay of direct deposit service.
| Full Name: _________________________________________ |
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Company Name: ____________________________________ |
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| Affiliate ID: _________________________________________ |
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Tax / Social Security #: _______________________________ |
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| Phone #: __________________________________________ |
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E-Mail Address: _____________________________________ |
Bank Information
Complete the following bank / financial institution information in the fields listed below. All fields are required to initiate a direct wire. Any questions can be routed through your affiliate manager.
Please detail your local bank account information
| Bank Name: _________________________________________ |
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Phone #: __________________________________________ |
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| Name on Account:_____________________________________ |
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Account #: ________________________________________ |
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| Swift Code: _________________________________________ |
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Wire Notes:_______________________________________ |
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| Bank Address: _______________________________________ |
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| Bank Wire Cost: $55 / Wire - Initial: _______________________ |
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Type of Account (Circle): Checking - Savings |
Intermediary Bank Information
Please detail your intermediary bank information. This is the United States branch of your bank that process funds internationally. If you are unsure of this information, please contact your local bank directly.
| Bank Name: _________________________________________ |
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Phone #: __________________________________________ |
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| Routing Number: ______________________________________ |
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Wire Notes:_______________________________________ |
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| Bank Address: _______________________________________ |
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*If this is an international wire, you will also need to provide your banks intermediary bank information.
Agreement
By signing this document I authorize Amped Media Inc to credit my account with the depository name above. The authorization will remain in effect until Amped Media Inc has received written notification from me that it is to be discontinued in such time and manner for Amped Media Inc to act on it. In the event my account becomes inactive causing the funds to be rejected and returned by the bank, the rejected portion will be sent in live check form via US mail to the company / personal address listed above. I understand that any incorrect information given on this form could delay credit to my account.
| Authorized Signature: ________________________________________________________ |
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Date: ___________________ |
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| Printed Name: _______________________________________________________________ |
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Title: ____________________ |
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