After you complete this form, click Print-friendly for a printable version, sign it, and return it to GCI via email or fax.

This form may be scanned and emailed to or faxed to any of our fax numbers available in our contact-us page.

Please be sure that you have completed all fields, including contact information and signature. Withdrawal forms that are not fully completed, submitted online and also signed and emailed to us will not be processed.

Affiliates withdrawing commissions: Input your Affiliate number for "Login Username" and put "affiliate commissions" for "Account Number"

Forms submitted with missing information are subject to delay.

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