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First Name

Last Name

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Please confirm that online poker is legal within the country you reside in:

Yes

No

What has been your annual profit from poker over the past 5 years?

<5k Profit / Year

$5k - $25k Profit / Year

$25k - $50k Profit / Year

$50k+

Please provide your alias for poker accounts played over the past three years and tell us about your current personal circumstances and your motivation for applying for staking:

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