| Choose Username & Password | |
| use A-Z and 0-9 characters for username | |
| CHOOSE UserName: | |
| CHOOSE Password: | |
| Account Information | |
| if please donot leave* blank | |
| Name on Check : * | |
| Company Name (optional): | |
| City:* | |
| Address 1:* | |
| Address 2: | |
| State/Province:* | |
| Zip:* | |
| Email:* | |
| Phone (optional): | |
| Country:* | |
| Bank Information(if you want your payment to be sent by wire) | |
| Bank Name: | |
| Bank Address: | |
| Bank City & State: | |
| Bank Country : | |
| Account Number : | |
| Name on Account : | |
| Routing Number : | |
| ABA/Swift Code : | |
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