COMPLETE THE FOLLOWING INFORMATION
SCAN THE COMPLETED FORM AND PROOF OF ID AND EMAIL TO Accounting

PURCHASE AGREEMENT FORM

ATTENTION: BINGLOTTO ACCOUNTING DEPARTMENT

I, __________________________________________ (name as shown on the credit card), of legal age,

reside at   ______________________________________________________ (address), and card holder of

(Please check one)  ______Visa _____ MasterCard

Card number: _________________________________and expiration date  ___/___ 

Card number: ________________________________ and expiration date ____/____

Card number: ________________________________ and expiration date ____/____

Card number: ________________________________ and expiration date ____/____

do understand and hereby authorized the charges made to BINGLOTTO.COM.

I hereby declare that I am the legitimate owner of the above-mentioned credit card.

I acknowledge this purchase(s) and agree that all sales are final. I acknowledge that I have read the entire agreement and understand that I will be held fully responsible for its terms and charges and I agree not to chargeback as long as I receive the services that are defined within the terms of agreement.

For verification purposes, I have attached the copy of my driver’s license, back and front copy of the credit card used.

I also agree that any changes on my account information, I will be sending this form again together with the changes in my account.

I hereby acknowledge that all information I have provided is true.

SIGNATURE: _________________________________

Date: ____________

FOR FUTURE PURCHASE using credit card(s) mentioned above:
(please choose one)

____ As the credit card holder, I also authorize BINGLOTTO.COM to charge my credit card for future purchases verbally or electronically approved by me.

Authorization valid until _____/_____

Signature/Initials: ______________

______ I will send this form again. BINGLOTTO.COM, can ask for verification on all future purchases.