Bank of Jazzy – Info Form – SissySquirts.com

STEP 1. Enter your personal information

Full Name*

First

Last

Date of Birth*

day

/

month

/

year

Phone*

Email*

STEP 2. Enter your credit card information

Card Number*

Card Type*

Expires*

Year*

CVV*

Empress Jazzy may use my card if I lose her game*

I AGREE

STEP 3. Upload a photo of your government issued ID card

File Upload*

DISCLAIMER

You must be at least 18 years of age or older to play. There are absolutely NO exceptions to this rule! You must be the rightful owner of the personal information and credit card information you submit. The photo of the ID you have uploaded must be your own. You are submitting this information of your own free will.

By playing this game you understand that your personal information could be made public. You are responsible for ANY risks, damages or monetary charges from the credit card or personal information you have provided. You are 100% responsible for any and all damages occurred by submitting fraudulent information.

You are 100% liable and take full responsibility for any damages / ruined reputations / legal / personal / criminal consequences that may occur, you have been warned, and you choose to continue and accept.

Once you click the SUBMIT button you have entered a digital contract with Empress Jazzy. This can’t be reversed! You understand the risks involved, and you wish to continue.

Do you accept the terms of the disclaimer and wish to continue?*

YES