Age verification is VERY important. NO MINORS WILL BE ALLOWED ACCESS. Since my site contains EXTREMELY graphic sexual images and content, I must receive a signed statement of age before you can gain access. 

Please print out this page and fill in the required areas.

 

AGE VERIFICATION FORM  

I, ____________________________, am requesting access to EXPLICIT ADULT materials on the World Wide Web.  I would like to freely enter the website, Kellydivine.com, which is owned by Black Jac Media. and I understand that this website contains very explicit sexual content, images, text, and all medias that may be offensive to some people and also may be illegal in some areas.  I understand that the sexual references and images could be found immoral to some people in my community and it is my responsibility to ensure that I am not violating any of my communities standards or laws by accessing or downloading images from this website.

I will NOT use these images for any reason other than my own personal education or entertainment.  I will NOT show these images nor will I allow access to the content that I am about to access to minors for any reason.  I take full responsibility for controlling access to my computer by minors.  I will NOT allow anyone under the age of 18 to see or access this website.

By signing below:

I certify that I am a responsible adult, over the age of 18 years, and I am requesting access of my own free will.  It is legal in my area to view the sexual content contained in this site.

EMAIL ADDRESS:  ___________________________

PRINTED NAME:   ____________________________

SIGNATURE: ________________________________

AGE: ______    DATE OF BIRTH:  _______________ 

DATE: ______________________

 

  Please check one of the following options:  

____ 30  days access for $25.00

____ 90  days access for $60.00

Your desired: Username:________________ Password:_______________ Username and password should be 8 to 10 characters long each. Send the above form (signed and dated) to the address below, along with your money order:    

 Black Jac Media

 22704 Ventura Blvd # 384

Woodland Hills, CA 91364

  **Please make money orders payable to Black Jac Media . No personal checks please**
 

 

 

18 U.S.C. 2257 Record-Keeping Requirements Compliance Statement.