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Independent Partner Application and Agreement

 

 

GEL ID Number (For Paper application only)
Mr/Mrs/Miss/Ms  
Last Name  
First Name  
Initials  
Address1  
Address2  
Address3  
City  
County / State  
Post Code / Zip  
Country  
Home Phone  
Business Phone  
Mobile Phone  
D.O.B  
Mother's Maiden Name  
Trading Name  
E-mail Address  
Sponsor GEL ID  
Sponsor Name  

Bank Details

 Please complete this fully to receive payments into your account
Bank/B.Soc Name  
Branch  
Sort Code  
Account Nunmber  
Account in Name of  

Card Details

    
Card Number  
Expiry Date  
Issue No.  
Card Type Visa, MasterCard/Solo, Switch, Delta
Name on Card  
Card Security Numbers found on the back of some newer cards