So heres the general layout:

Clan Application

Clan name: EPIC
Clan tag: [EPIC]
Link to your clan's thread: http://forum.toribash.com/showthread.php?t=270542
Clan subtitle: We Are Who We Choose To Be
Leaders name: ConCon19
Moderators you want for your board: ConCon19, Oimanoi and Chaossook
If you get rejected, who to send the 30k refund to: EpicClan

Everything ok?