International Athlete Bank Information

Affiliate Name(Required)

Email Address(Required)

I (we) hereby authorize Nutrex Research, Inc., hereinafter called COMPANY, to initiate credit entries to my (our) account at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same to such account. I (we) acknowledge that the origination of Bank Wire Transactions to my (our) account must comply with the provisions of U.S. law.

Start Date(Required)

Account Type(Required)

Checking

Savings

Bank Name(Required)

Name on Account(Required)

Address(Required)

SWIFT or BIC Code(Required)

Routing Number(Required)

Account Number(Required)

Signature(Required)

Date(Required)

Acknowledgment(Required)

I acknowledge

I (we) understand that this authorization is to remain in full force and effect until I (we) notify COMPANY, in writing, that I (we) wish to revoke this authorization. I (we) understand that COMPANY requires least 15 days prior notice in order to cancel this authorization.

NOTE: ALL WRITTEN CREDIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.