Fax Back Verification Form [ Print Form ]
I certify that the electronic media record of my transaction held byPokeropolis.com shall be used as the final determination to resolve any dispute I may have. I acknowledge that I have read all the information contained in the Pokeropolis.com License and agree to abide by all the rules, terms, conditions, and agreements therein and as may be amended from time to time.
(Please complete, in clear letters, one form for every credit card you have used)
Name (as shown on account) ___________________________________Username_____________________
Address Line #1 ___________________________________________________________________________
Address Line #2 ___________________________________________________________________________
City _____________________________________State ___________________________________________
Zip/Postal Code ___________________________Country _________________________________________
Home Phone ( _____ ) _______________________Fax ( _____ ) ___________________________________
Work Phone ( _____ ) _______________________E-mail _________________________________________
Date of Birth _____ / _____ / _____ (mm/dd/yyyy)
Type of Card: ____________________________________________________________________________
Credit Card Number: _______________________________________________________________________
Expiration Date: ____ / ______ (mm/yyyy)
Name as shown on card: ____________________________________________________________________
Also remember to send us a visible copy of your driver's license or other form of official photo I.D. as well as a copy of each credit card used (front and back).
*Please accept this as authorization for Pokeropolis.com, to draft the above listed Credit Card and continue such authorization until I notify Pokeropolis.com and the bank listed in writing.
Signature ____________________________________________ Date ____ / ____ / ____