TM
Distributor Information
First Name:
Last Name:
Company:
SSN or Tax ID #
Re-type SSN or Tax ID #
Address:
Street Address 2
Street Address 1
State:
City:
Zip:
Country:
Contact Information:
Phone:
Email Address:
Sponsor Information:
Sponsor Name:
Sponsor ID:
Site Information:
Username/Sitename:
Password:
* For example, whatever username you choose will also be your sitename and your website URL would be
sitename.gamelootnetwork.com
Fun Pack options:
(Choose a fun pack below)
Fun Pack 500
$100
plus $50 a month
Includes 500 Game LootTM
token PLUS 250 tokens a
month
Qualified as a Game
Ambassador
Fun Pack 1250
$250
plus $50 a month
Includes 1250 Game
LootTM token PLUS 250
tokens a month
Qualified as a Game
Ambassador
Fun Pack 2500
$500
plus $50 a month
Includes 2500 Game
LootTM token PLUS 250
tokens a month
Qualified as a Game
Ambassador
Fun Pack 5000
$1000
plus $50 a month
Includes 5000 Game
LootTM token PLUS 250
tokens a month
Qualified as a Game
Ambassador
Please complete and email a scanned copy to [email protected] or fax to (816)600-4222
TM
IMPORTANT: You must add a 1-time $29.95 Game Ambassador
fee to your order when mailing your payment.
Billing Information:
Enter your credit card information below for the monthly auto-purchase of your Fun Pack 250 ($50 a month)
Card Holder Name:
Expiry Date:
Card Number:
CVV Digits:
Billing Address:
Street Address 2
Street Address 1
City:
State:
Country:
Zip:
Please mail your cashiers check or money order to the address below and email a scanned copy of this
application to [email protected]. You may also send a bank wire by using the information
below, but you will need to email us a scanned copy of your bank wire to [email protected]
so that we may be able to quickly and accurately track your payment and post it to your account.
Game Loot LLC
4120 NE Port Drive
Lee’s Summit, MO 64064
Bank of America Wiring Instructions:
Name on Account: Game Loot LLC
Routing #:026009593
Account #:518007499119
IMPORTANT: You must add a 1-time $29.95 Game Ambassador fee to your order
when mailing your payment.
Signature and Date
Please complete and email a scanned copy to [email protected] or fax to (816)600-4222