Welcome to VALIS International !

Personal USA Checking Account with Affiliate Packages
ORDER FORM

Choose your Program
	PLATINUM: 1st Class US Address + Premium Affiliate Program with US Checking Account and MasterCard Debit Card ($420 +$100 postage deposit + $130 opening bank deposit) US Office Address for 1st Class flat mail forwarding -- $300/year to maintain + Postage Includes courier/Global Priority Traceable mail of checks and MC Earn $25 per referred client or $50 per referred Client using our Address
	GOLD: US Checking Account and MasterCard Debit Card and Premium Affiliate Program ($120 + $130 opening bank deposit) No US Address supplied or required Includes courier of checks and MC Earn $25 per referred client or $50 per referred Client using our Address
	SILVER: US Checking Account and ATM Card with Premium Affiliate Program ($100 + $100 opening bank deposit) No US Address supplied or required Earn $25 per referred client or $50 per referred Client using our Address
	Free Affiliate Program -- Earn $25 per referred client -- no account

	Upgrade your Account to include Internet BillPay (+$3/month account fees)

How you found us:

A. Who You Are
Full Name:
e-mail address (use the address given to you by the ISP you are using to connect) (no webmail or free addresses- hotmail, etc.):
Your Site:
First Name:
Middle Initial (Optional):
Last Name:
Mothers Maiden Name:
Home Phone Number: (We will call you to confirm this)
FAX: (include country code)
Date Of Birth:
Driver's License # and Province/Country:
Passport #:
Home address
Street:
Additional Street
City:
Province / State:
Postal Code:
Country:

B. Affiliate and Login Info
Preferred User Name (Affiliate/Login ID):
Password and Password Confirmation (6-10 characters):

C. Mail Forwarding Address (Complete only if ordering GOLD or PLATINUM)
Street:
Street (additional):
City:
Province / State:
Postal Code:
Country:

D. Payment Information
Preferred Payment Method:

E. Purpose of US Account and/or Address
What will you be using the US Checking account and/or US address for?	To receive VALIS affiliate payments and

Requirements:
emailed to us:
scan of Passport
scan of paper Telephone Bill and/or bank or credit card statement
+
Mailed/couriered to us:
signed and dated Signature Card (we supply)
signed and dated W-8BEN (we supply)

90% of our clients choose GOLD

we serve clients from over 50 countries and growing