Credit Card Registration Form

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 Hansa Poker 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 Hansa Poker 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   MM      DD      YY    Purchase Method   Card Number Expiry Date   MM      DD      YY    Name as shown on card Bank Name     Please accept this as authorization for Hansa Poker to draft the above listed credit card and continue such authorization until I notify Hansa Poker   and the bank listed in writing. By this I authorize Hansa Poker to charge my card and I authorize all purchases made by me at Hansa Poker. 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: