Payment Details - Form - Segalo Media

Please Fill out the Form:

Name

First Last

Phone

List Your Country of Residence:(Required)

Country

How would you like to be paid?(Required)

ACH is the fastest and cheapest way to receive money within the USA. Paypal will incur fees.

How would you like to be paid?(Required)

What is your Paypal email address?

Note: Paypal incurs transfer fees that will be deducted from your payment.

What is your Wise email address?

Note: Wise incurs small transfer fees that will be deducted from your payment.

Paypal Address (Backup)

In case Wise is unavailable or doesn't work at the time of transfer, we need your PayPal for backup.

Please fill out the fields below:

I authorize Segalo Media, LLC, to initiate monthly withdrawals from the below designated account. I understand that both the financial institution or Segalo Media, LLC have the right to terminate this payment method at their discretion. I also understand that I may discontinue this payment method at any time with a written revocation of this authority.

Account Holder Name

Bank or Financial Institution Name

Routing Number

Account Number

Confirm Account Number

Address