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To become a Preferred Member with Pay-Pro, please print and complete the below
form and send it to fax # +1 (206) 203-5045 along with a CLEAR copy
of your 1) drivers license, 2) voided check and 3) copy of the front
and back of your credit card or ATM. Alternatively you may scan and
email this form and its attachments to efax@pay-pro.com.
Account Name _______________________________ at Site Name
___________________________________________________
First Name _______________________________________ Last Name
________________________________________________
Home Phone __________________ Work Phone
_________________________Date of Birth (MM/DD/YY) ___ /___ /_____
Social
Security or Tax ID Number_________________ Home Address ________________________________________
_________________________________________________________
City _______________________ State
__________________ Zip ____________________Country ___________________________Credit Card Number ________________________________
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 Number__________________________
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 _______________________________ |
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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. |
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Fax or Scan and email the above form along with a clear copy of
your 1). drivers license, 2). voided check and 3). front and back of
credit card or ATM to one of the following:
Fax Number #: +1 (206) 203-5045
Scan and e-mail to: efax@pay-pro.com
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