Client Name
Company Name
Address
Contact Information
Genealogy Report:
.All Intermediaries will be paid by the intermediary paymaster.
CLIENT NAME:
TRANSACTION TYPE: (i.e..cash, bank instrument, bond, etc.) ?????
TRANSACTION CODE: (Assigned by Program Provider)
CLIENT CODE: (Assigned by Investor / Client)
BROKER COMMISSION: Even Distribution
Consultant 1/Facilitator (Direct to Platform): Consultant 2 (Direct to Facilitator):
Printed Name : Printed Name :
Company: Company:
Nationality: Nationality:
Passport #: Passport #:
Tel: Cell: Tel: Cell:
Fax: NA Fax:
Email: Email:
Skype: Skype:
Commission share and basis: Commission share and basis
Consultant 3: Consultant 4:
Printed Name : Printed Name:
Company: Company:
Nationality: Nationality:
Passport #: Passport # :
Tel: Cell Tel: Cell:
Fax: Fax:
Email: Email:
Skype: Skype:
Commission share and basis: Commission share and basis
Consultant 5: Consultant 6:
Printed Name : Printed Name:
Company : Company:
Nationality: Nationality:
Passport # : Passport # :
Tel: Cell: Tel:
Fax: Fax:
Email: Email:
Skype: Skype:
Commission share and basis Commission share and basis
To the Paymaster:
We hereby confirm that the list of beneficiaries above is complete and the only parties entitled to a share
Client Name
Company Name
Address
Contact Information
of the gross commissions payable in respect to the Transaction code ………………
The Beneficiaries agree to absolve the Paymaster of any legal, contractual or other liability in the event of
third parties requesting that the Paymaster pay them in respect of the Transactions, in a case where the
relevant Beneficiaries did not inform the Paymaster of any such third parties being entitled to Payments
from funds received by the Paymaster
Signed by …………………………….
On behalf of all beneficiaries as listed
date