40%+ Rakeback sign up

To sign up for the www.futurepoker.net 40%+ rakeback offer please fill out the form below remember you must have joined up and downloaded the software through www.futurepoker.net to recieve this offer if you have not joined up please do so here!
do you wish to sign up for futurepoker.net 40% rakeback
yes
no

MULTI-POKER USERNAME
*FIRST NAME
*LAST NAME
*EMAIL ADDRESS
ADDRESS
ZIP/POSTCODE
COUNTRY
how would you like to recieve your rakeback
neteller
check
bank transfer

NETELLER ACCOUNT NUMBER
*email address must be the same as the one you joined up for at neteller for you to recieve payments!
BANK NAME
ACCOUNT NUMBER
BIC/SWIFT

If you wish to be paid via neteller (instant) you can get a free account by visiting www.neteller.co.uk remember email addresses used on this form must be the same as the one you joined up with your neteller account.

WHERE DID YOU HERE ABOUT FUTUREPOKER
SEARCH ENGINE
FRIENDS
RAKEBACK SITE
EMAIL AD
MAGAZINE
ROKER ROOM