Jersey Request Form
100$ or BTC equivalent
Name (or nym)
*
First Name
Last Name
Email
*
example@example.com
What Size are you?
*
Please Select
Small
Medium
Large
Xtra Large
Do you want a name on the back? (+10$)
Type it here
What Color do you want?
*
Dark Blue
Powder Blue
Where should we send it? (Leave blank if you'll pick up at the meetup)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many would you like?
*
Would you like to pay in Bitcoin?
*
Please Select
Yes
No
Anything else we should know?
Do you want multiple sizes, colors, names, etc
Pre Pay in Fiat
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( X )
Bitcoin Bay Jersey
$
100.00
Size
Quantity
Color
Name?
Price
M
1
2
3
4
5
6
7
8
9
10
Dark Blue
Powder Blue
No
Yes
$
100.00
S
1
2
3
4
5
6
7
8
9
10
Dark Blue
Powder Blue
No
Yes
$
100.00
L
1
2
3
4
5
6
7
8
9
10
Dark Blue
Powder Blue
No
Yes
$
100.00
XL
1
2
3
4
5
6
7
8
9
10
Dark Blue
Powder Blue
No
Yes
$
100.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit
Should be Empty: