Official ClubBucks Merchant Affiliate Application (PRINT OUT THIS FORM)

Your DHS Club Member ID *(If you do not have an ID Number, one will be assigned)  
Referral ID Number  
Personal First Name  
Personal Last Name  
Personal Email Address  
Name of Business  
Address of Business  
City  
Country  
State/Province  
Postal Code  
Business Phone Number  
Business Fax Number  
Business Email Address  
Business Website Address (URL)  
Type of Business  
Create a Username  
Create a Password  
Contact Name  

Is this business a Publicly held Corporation? ______________________________________

Is this business a Privately held Corporation?_______________________________________

Select the Merchant Discount you wish to offer:

Membership Type Description Total Discount Reward Points
(based on each U.S. Dollar spent)		 Referral Fee Pay Points % Merchant Pay Points% Your Choice
Bronze 3% 2 points 0.25% 0.25% 0.125%
Silver 6% 4 points 0.50% 0.50% 0.25%
Gold 10% 6 points 1.00% 1 .00% 0.50%
Platinum 15% 10 points 1.25% 1.25% 0.625%
Special Exception* Negotiated TBD TBD/NA TBD/NA TBD See Below
 
Special Exception* Merchants fall into two categories:

First, are those businesses that may offer larger ticket items and operate on smaller profit margins (car dealers, boat dealers, etc) and would like to negotiate a smaller discount percentage or a flat rate.

Second, are those businesses, which by law are unable to pay a referral fee or commission (real estate broker, medical, etc.) In this instance, the applicable percentages would be included in the rebate and possibly in the SIAM.

Special Exceptions I wish to offer ____________% to a maximum of $____________
 Or Other: _______________________________________________________

Account Holders Information

Name  
Address  
City  
Country  
State/Province  
Postal Code  

Payment Method: (NOTE: Checking Account option is only available in the US.)

Credit/Debit Card Number
Example: (123456789012 no spaces)
Debit Cards must have a VISA or MasterCard logo on it.
Credit Card Code    Card Code Help
Credit Card Expiration Date Month Year
                      - OR -                     (REMINDER: Checking Account information is only valid in the US.)
Checking Account Number
Example: (123456789012 no spaces)
Debit Cards must have Visa or Master Card logo on them)
Bank Routing Number
Example: (123456789 no spaces)

NOTE: You will be required to submit a voided check or facsimile thereof with your application
if you choose to pay by check.

** Please note: We will authorize your card information by submitting an "Authorization Only" transaction for $0.01.
This is to verify your credit card information only, and will not actually be charged to your card.

I acknowledge that I have read and agree to the ClubBucks Merchant Affiliate Terms and Conditions.

____________________________________________________/__________________
Signature of Business Owner or Manager /Date

 

Need to register another location? Click Here

Fax or Mail this signed application to:
The DHS Club
2560 Placida Road
Englewood, FL 34224
FAX : 941-475-4081

Acceptance of this application by the DHS Club is not to be considered an approval of the application as it must be manually processed by our HQ Staff during normal business hours.

revised 1/19/05 LY