I, the undersigned, declare and confirm that the attached is a true copy of my original passport or drivers license and belongs to me. By signing below, I am authorizing you to gather information about me from my bank, credit bureaus and others to verify my identity and to determine my eligibility for credit, renewal of credit, and future extensions of credit.
To process this form, it must be accurately completed and verifiably correct.
First Name: _______________Last Name: _____________________
Phone: (____) _______ - __________ Fax: (____) _______-__________ (optional)
Bikini Poker User Name: _________________ Date of Birth: ______/_____/_____ MM / DD / YY
VISA or MasterCard You Will Be Using To Make Deposits
Primary Credit Card Account #: ________________________ Expiration Date: _____/_____
Issuing Bank: _____________________ Customer Service Telephone: ___________________
Secondary Credit Card Account #: ______________________ Expiration Date: _____/_____
Issuing Bank: _____________________ Customer Service Telephone: ____________________
Tertiary Credit Card Account #: _______________________ Expiration Date: _____/_____
Issuing Bank: _____________________ Customer Service Telephone: ____________________
Billing Address For Credit Cards (must be same address for all cards above)
Street Address: ____________________________________________________
City: _____________________________ State: __________________________
Country: __________________________ Zip Code: _______________________
Date: _____/_____/______ MM / DD / YY
Signature
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