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ARTIST PAYMENT INFORMATION
Artist First Name
*
Artist Last Name
*
Cooperative Name
Country
*
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cabo Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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?)
*
WIRE TRANSFER INFORMATION
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:
*
INTERMEDIARY BANK - TO BE USED IF YOUR BANK HAS NO SWIFT CODE
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:
*
ACKNOWLEDGMENT
I CERTIFY THAT ALL INFORMATION ABOVE IS TRUE.
*
YES
PLEASE SIGN BELOW:
*
clear
TODAY'S DATE
*
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