To become a IslandPoker.com
Document Verified User, please print
and complete the below form and send it to fax # + 1 (253) 663-1992 along with
a CLEAR copy of your 1) drivers license, 2) voided check and 3) copy of the
front and back of your debit or credit card. Alternatively you may scan and
email this form and its attachments to cashier@islandpoker.com.
Please note that all information
must be completed and verifiably correct.
Sign In Name ____________________
at IslandPoker.com
First Name _______________________ Last Name ________________________________
Home Phone _____________________ Work Phone _______________________________
Date of Birth (MM/DD/YY) ___ /___ /___
Social Security # ,Tax
ID # or Foreign Equivalent _________________
Home Address ______________________________________________________________
City __________________________________ State ________ Zip ____________________
Country _______________________________
Credit Card # ______________________________________
Expiration ________________
Issued By ________________________________________________
Do you receive your credit card statement at your above home address?
Yes/No (Circle One)
If no, provide Billing Address: ___________________________________________________
City __________________________________ State ________ Zip _____________________
Country _______________________________
Checking Account #__________________________
Bank Name _______________________
Do you receive your checking account statement at the above address?
Yes/No (Circle One)
If no, provide Billing Address: ___________________________________________________
City __________________________________ State ________ Zip _____________________
Country _______________________________
I, the undersigned, declare and confirm that the above information is true and
correct, and that the attached documents are also true and correct copies of
my valid identification and banking information. By signing below, I authorize
IslandPoker.com and its agents 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 extensions of credit.
Signature: ______________________________ Dated: ________________(MM / DD
/ YY)
Fax, scan and e-mail or mail the above form along with a clear copy of your
1). drivers license, 2). voided check and 3). front and back of debit or credit
card to one of the following:
Fax Number:+ 1 (253) 663-1992
Scan and e-mail to: cashier@islandpoker.com
Mail to:
Action Poker Gaming Inc.
P.O. Box W1879
St. John's, Antigua, West Indies
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