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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)
Texas Hold'em Poker Account Name: __________Date of Birth:
______/_____/_____
MM
/ DD / YY
Social Security Number (or Foreign Equivalent):
____________________________
Credit Card and Checking Account
Information
Credit
Card No.: ___________________________ Expiration
Date: _____/_____
Checking Account Number:_______________________________
Billing Address
Street
Address: ____________________________________________________
City: _____________________________ State:__________________________
Country: __________________________ Zip Code:_______________________
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