Right click here to download the registration form

globestupendousΑσφάλεια

3 Δεκ 2013 (πριν από 3 χρόνια και 8 μήνες)

86 εμφανίσεις

JUMA

E
-
Currency Purchase Registration Form





DISCLAIMER AND SIGNA
TURE

I certify that
the above information that I am submitting is true and correct.

Signature


Date



Please scan a copy
(Front

and
Back)

of the
above identification card and attach it with this
form and email

them to

jumaone@jumaxa.com

Please put registration in the subject line

of the email
.

Once we receive the registration form and copy of identification it will be
kept on file

offline. It
will never be used for any purpose but

for purchase validation. The information above


(Name and Address) must match the information your credit card company has.

All purchases of BITCOINS and LITECOINS will be sent to the addresses above only!

If you need to update the wallet addresses or hom
e address please email
jumaone@jumaxa.com

and we will send you what you need to update the information!

REGISTRATION

INFORMATION

Last Name


First


M.I.

Date


Street Address


Apartment/Unit #


City


State


ZIP


Phone


E
-
mail Address


Last four digits of Social Security No. (If available)


BITCOIN Wallet
Address:


LiteCoin Wallet Address:


PURCHASE CONFIRMATIO
N

CODE

Code that you want used for purchase confirmations ( please create a
n

eight

digit

numerical
code)

This will be your digital signature


IDENTIFICATION VERIF
ICATION

Please list three

professional references
.

Type of Identification:
(Check one)

Passport

Drivers License

State or Provincial Identification card

Other

Registration number or number on the
form of identification used:


Address

on identification used ( Must
match the address on your credit card )


Street Address


Apartment/U
nit #


City


State


Street Address