ARTIST PAYMENT INFORMATION

Artist First Name *

Artist Last Name *

Cooperative Name

Country *

Phone Number *

Email Address *

HOW WOULD YOU PREFER TO BE PAID? *

Wire Transfer (Currency USD)

Check (issued to a US based person or organization)

CHECK INFORMATION

Issue check payment to: (individual or organization) *

Mailing address: (where should the check be sent?) *

Beneficiary Bank Name (your local bank): *

Does your bank have a swift code? *

YES

NO

Swift Code of Beneficiary Bank: *

CLABE number in Mexico (18 digit Number – required in Mexico): If you are not an artist from Mexico, please enter "NA" *

IRC (Required for India): If you are not an artist from India, please enter "NA" *

ABA / Routing number *

Bank address: *

Bank telephone number: *

Beneficiary name (name on bank account) *

Beneficiary bank account number (IBAN for India) *

Beneficiary address: *

Name of intermediary bank: *

Swift Code of intermediary bank: *

Bank ABA / Routing number: *

Account number (not always needed)

Intermediary bank address: *

Bank telephone number: *

Any other special instructions: *

I CERTIFY THAT ALL INFORMATION ABOVE IS TRUE. *

YES

PLEASE SIGN BELOW: *

clear

TODAY'S DATE * +