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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)
EmpirePoker 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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