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: Dickysitestaff@gmail.com Put in subject line " Application " Please note: this is only avaliable to United States and Canada 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	Credit card Authorization	Member Usage

Contact Name regarding questions on application
Your user name:
Contact First Name:	Contact Middle Inital:	Contact Last Name:
Contact Address:	Contact address: (optional)	Contact City:
Contact State:	Contact Zip Code:	Contact Email:
Contact Phone Number: () - -	Contacts birthday: mm dd yyyy / /	Do you want Dicky Site Contact you when your credit card has been used? Yes No If yes how do you want us to contact you? by phone or e-mail

Application Fee: There is a $100 non-refundable application process fee. Then a $30Dollar application fee if you change your information below.
Money Order Cashiers Check Cash Personal Check Credit Card	Made Payable to: Jason Dickens 6238 Rockdale Ct Burlington, ky. 41005 United States

Credit Card Authorization: Please note: The cardholder must be the owner named on this Application
Credit Card type: Master Card Discover American Express Visa	Credit Card Number:	Expiration Date:     CSC: mm 01 02 03 04 05 06 07 08 09 10 11 12 / yy 09 10 11 12 13 14 15 16 17 18 19 20      What is CSC?
I am an authorized signer on above card If I selected the credit card payment option I authorize Dicky Site to charge to my credit card of $100 dollars. Initial here for acknowledgement
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. That I authorize Dicky Site to contact me at either e-mail address or phone number that is listed when my credit card is used on Dicky Site but excluding links to other websites outside of Dicky.ucoz.net to help me and Dicky.ucoz.net from Credit card fraud if only I selected to contact me with the option listed above. 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 $100 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 $100 dollars making it $125 dollars total. Also before I use a new credit card, or change address, telephone number, E-mail address, that will help me and Dicky site to combat Credit card fraud I must resubmit a new application with a $30 dollar non-refunable fee. I understand and agree to these terms that Dicky site will contact me when my credit card number is used within Dicky Site excluding outside links relating to a different website That Dicky.ucoz.net is hosting. Dicky site can not verify me by those sites and that I must take caution when purchasing on the site unless the site is stated to be owned by Dicky site. I also understand that Dicky.ucoz.net may not be able to verify me by the purchasing other peoples products with in Dicky.ucoz.net. 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. I also understand that If I don't want Dicky Site staff members contacting me that I must submit every reciept to Dicky Site staff. 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: