Tournament Payment Details – Card

Please complete and submit the following details as soon as possible exactly in the way requested. These personal details will support FairBreak’s ability to provide you with a physical or virtual per diem debit card. These details will be kept in confidence and managed in accordance with FairBreak’s Privacy Policy. Disclaimer: Please note that FairBreak relies on the accuracy of your information and cannot be responsible for misdirected payments where information supplied proves not to be accurate.

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PERSONAL DETAILS

These details must be your full legal name as found on any Government issued documents that you hold. Middle name is optional.
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Please enter as Day - Month - Year. This information must be provided.
Please enter your primary contact email address.
Please enter your correct country code and then your number. The form should detect the country in which you are completing your form. If this is not your normal country of residence, please correct the country code. This number may be used to send two-factor security authentication codes or to contact you for any payment or per diem card related enquiries.

RESIDENTIAL ADDRESS

Please complete for your normal residential location.
Please select correct country.
Please complete your physical residential address location. e.g: 123 Example Street, or Apartment X, 123 Example Street. Please do not enter a post office or parcel receipt location.
Please enter your home city or town of residence.
Please accurately enter in full the State or Region in which your home city or town is located.
Please accurately enter the postal code, if any, associated with your residential address.
Please enter any additional address information we may need to be aware of to clarify your physical address.