Credit card number (no dashes, just the numbers):
The expiration date is just as important as the card number.
Month 01 (January)02 (February)03 (March)04 (April)
05 (May)06 (June)07 (July)08 (August)
09 (September)10 (October)11 (November)12 (December)
*** If you can't see the date that is on your card, then put anything here and put the correct date in the comments box below.
Name of issuing bank or company (like XYZ Bank). This is probably on
the front of the card, and is not just "Visa" or "Mastercard"
Bank telephone number. This is on the back of your card,
and probably begins with 800 or 888, 877, 0345
Digits on signature strip. This is on the back of your card,
where you sign it. It is a bunch of digits printed there
Name (first): (last):
State or County:
Postcode or Zip:
Phone (optional): Country () area ()--
Check this box if you are over 18 and above the legal age of consent in your location
A username should include at least three letters and at least three numbers.
Don't use accented letters. Don't use the same password that you use on any other system.
Comments - these are optional, of course. If your address is not the same
as the cardholder's address, it could go here; also any comments or suggestions
on the site:
Email address of recipient:
Length of membership:
A message to the recipient from you (optional)