LICENSOR PAYMENT AUTHORIZATION FORM
Todays Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Email
*
example@example.com
Payee Name
*
Payee Address Where Payments are to be received
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Amount
*
Due Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Payment
*
Wire
Check
Contract Name
*
Contract Number
*
Is an Insurance Certificate Needed?
*
Yes
No
Reason
*
Minimum Guaranteed Royalty
Amended Agreement / Minimum Guarantee Payment
Other
*
By Checking this box I am signing on behalf of Primitive's Licensing Manager and their approval
Signature
*
Date Signed
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: