To ensure your application gets processed as quickly as Possible Please type the information in the following forms provided in the checklist and sign in the indicated locations All forms are required and must be completed Before the Application is processed Please print and Mail to: Jason Dickens 6238 Rockdale ct Burlington, Ky. 41005 United States Or Email This form with a photo I.D. to: Dickysite@gmail.com Put in subject line " Application " Please note: this is only avaliable to United States Only Please allow 7 to 14 days for your application to be processed by snail mail, or 4 days by e-mail.

Check List
Photo I.D. ( Drivers license or Passport )	Application Fee	Member Usage

Contact Name regarding questions on application
Your country: >-- Choose a Country -- United States Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Republic Bahamas Bahrain Barbados Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Canada Cape Verde Cayman Islands Chad Chile China Colombia Comoros Cook Islands Costa Rica Croatia Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador El Salvador Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia Gabon Republic Gambia Germany Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guinea Guinea Bissau Guyana Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lesotho Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Mongolia Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Niue Norfolk Island Norway Oman Palau Panama Papua New Guinea Peru Philippines Pitcairn Islands Poland Portugal Qatar Republic of the Congo Reunion Romania Russia Rwanda Saint Vincent and the Grenadines Samoa San Marino São Tomé and Príncipe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Vanuatu Vatican City State Venezuela Vietnam Wallis and Futuna Islands Yemen Zambia		Your user name:
Contact First Name:	Contact Middle Inital:	Contact Last Name:
Contact Address: (line 1)	Contact address: ( line 2 ) (optional)	Contact City/Town:
Contact State/region/providence:	Contact Zip Code/Postal code:	Contact Email:
Contact Phone Number:	Contacts birthday: mm dd yyyy / /

Application Fee: There is a $50.00 non-refundable application process fee.
Money Order Cashiers Check Cash Personal Check Credit Card *Payable by paypal	Made Payable to: Jason Dickens 6238 Rockdale Ct Burlington, ky. 41005 United States

Signature:		Must be signed not typed

Date Recieved: Internal use only

Date Cleared: Internal use only

Member Site Usage: Just incase the forget password does not work. This is what Dicky Site will use if I can not log in or reset password
Your Username:	Secret Question:	Secret Answer:
E-mail address: *must be the same address that you used to sign up on the site

Authorization: I hereby that all the information is correct and accurate to the best of my ability. I agree that this is my information and not anyone else and that this is my signature signed below. This is my correct number, Physical address, My real name. The e-mail address that is listed is the one that I signed up for on this site Also I understand that If I do something to get my account terminated from this site that I must resend the $50.00 USD dollars and the application which is non refundable to be reactivated on this site. I also understand that if I write a cold check there will be a $25 dollar fee on top of $50.00 dollars making it $75 dollars USD total. I also understand that Dicky Site will keep this information safe from other people and members and it will only be used by Dicky Site staff. I also agree that If I sign up for a different person that this application is null avoid which means this application does not work if the person I signed up for is not me. I Also I agree that I will send a copy of a photo I.D. ( Passport, and/or Drivers license ) with this application to verify its me the owner of this application to protect myself with credit card fraud. Intital here Please Make sure to provide all the information that has been requested in order not to delay and to ensure fastest processing time

Print name:
Signature:				Date:
Time: