Dollar Store Verification Application
Name
*
Prefix
First
*
Last
*
Suffix
Email
*
Liberty Reserve Account Number:
*
Invited By
*
How would you like to be paid?
LR Account
Debit Card
To the best of your ability please put the number of positions purchased for each month payout.
Example: Lets say you purchased 2 positions for April payout & 3 for June payout, in the April field you need to enter in #2 & the June field you will enter
April
June
July
August
September
Notes
Image Verification
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