Payout Request Form - Bank Account

Submit your Bank payout request form.

Please fill this form to begin the payout process to your bank account. Please remember that each transaction has a 5% transaction fee for bank payouts.

Name of Bank

Country

Account Type *

Receiver Information

Requested By *

Nombre

Apellidos

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone

Date of Birth

Payout Information

Date Requested

Amount Requested

Bank Details

Name of Account Holder

Routing Number

Account Number

Confirm Account Number

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