Personal Information

Full Name:
City:   State:
Zip Code: Date of Birth: / /
Day Phone: Evening Phone:

Card Information

Card Number: - - -   Expiry Date: /
  *The 16 digits on front of your card   *(MM/YY)
Card Number: - - -   Expiry Date: /
  *The 16 digits on front of your card   *(MM/YY)

Legal Statement

I certify that the electronic media record of my transaction held by Bingo Flash shall be used as the final determination to resolve any dispute I may have. I acknowledge that I have read all the information contained in the EMONEY PROCESSING LTD License and agree to abide by all the rules, terms, conditions and agreements therein and as may be amended from time to time.

I also certify that the credit cards listed above have been registered with Bingo Flash and used there with my full knowledge and consent.

Signature Date

Return this completed and signed form to us along with a visible copy of your driver's license or other form of official photo I.D. as well as a copy of each credit card used and a utility bill or bank statement with your printed address on.

We will accept scanned copies or digital photograph of these documents. You can email them to us on below email addresses.

Email: and CC:

If you have any questions or concerns regarding how your credit card billing will appear, please feel free to send us an email or contact our Customer Service.

Make an imprint of your embossed credit card

  1. Place card under the authorization form
  2. Rub pencil very light over the card
  3. Ensure that name, number, and expiration date are clear and readable.