::Kompolt:: Incubus 2009 Wrap Up Charity Auction Pre-Qualification Form

Thank you for your interest in the Incubus 2009 Wrap Up charity auction

To start the Pre-Qualification process, please provide the following information:

eBay ID:		Not an eBay member? click here!

Do you have a credit card on file with eBay?		eBay requirement for bids of $15,000 or more

Email Address:		Address must be linked to the above eBay ID

First Name:

Last Name:

Billing Address:		Address must match credit card or bank account that you wish to use for Pre-Qualification

Address 2:

City:

State/Province:

Zip/Postal Code:

Country:

Phone #:		ex: 555-555-1212

Alt Phone #:		ex: 555-555-1212

How did you hear about the auction:

Notes:

	*After you submit this form, a Kompolt representative will review your information and contact you via phone to complete the Pre-Qualification process.