Blonde Poker Online

Faxback Form
Please fill out the form below, sign, then fax to +44 207 681 1260. This information is used to ensure payment goes to the proper recipient and to prevent fraud.

I certify that the electronic media record of my transaction held by Blondepoker shall be used as the final determination to resolve any dispute I may have. I clearly understand it is my sole responsibility, if applicable, to report my financial information to my respective Government, Customs, or Tax jurisdiction. I acknowledge that I have read all the information contained in the Blondepoker license and agree to follow by all the rules, terms, conditions, and agreements therein and as amended from time to time.

Please complete one form for each credit card you have used (i.e., multiple forms).

Player ID (as on account):

Full Name (as on account):

Address Line #1:

Address Line #2:

City

State

Country

Home Phone

Work Phone

Fax

Email Address

Home Address

Date of Birth

Purchase Method

Card Number

Expiry Date

Name as shown on card

Bank Name

Please accept this as authorization for Blondepoker to draft the above listed credit card and continue such authorization until I notify Blondepoker and the bank listed in writing.

By this I authorize Blondepoker to charge my card and I authorize all purchases made by me at Blondepoker. I understand that the charges will appear on my credit card statement as Aquapay.London.

I further agree that this payment is final and irreversible.

Signature:Date:

Banking

Credit Card Registration Form