go to black jack
Credit Card Agreement Form
Dear
Valued go to black jack Casino Member,
go to black jack Casino
appreciates your business! You must completely fill out this form.
go to black jack Casino requires a legible signature on this form.
This form must be accompanied with a photocopy of the front side of
your Driver’s license or passport and a photocopy of the front and back
of your credit card (s) that you have used to deposit. Your credit card(s)
will only be used for the purpose intended, and will be charged for
the specified amount you authorize. This form will act as a permanent
signature on file for any previous or future credit card transactions.
Credit
Card(s) #___________________________ Exp. Date _____/_____
Credit
Card(s) #___________________________ Exp. Date _____/_____
Credit
Card(s) #___________________________ Exp. Date _____/_____
Credit
Card(s) #___________________________ Exp. Date _____/_____
Credit
Card(s) #___________________________ Exp. Date _____/_____
Date of Birth: ______/______/______
Player PID (Username) ________________
Name: ________________________
________ _________________________
(First)
(Int.)
(Last)
Address: __________________________________________________
City: _________________ State______________ Zip _______________
Phone # (____) _______ - _______ Fax: (____) ________- __________
Email Address: ______________________________________________
I ________________________________________, knowing that my account information
is private and it is my responsibility to maintain the privacy of my account,
hereby authorize go to black jack Casino to charge my
credit card(s) for all deposits made into my account. I
further agree that this payment is irrevocable.
Cardholder’s Signature: _____________________________________
Date: ______/______/_______
Please complete and return all information using any one of the following
methods:
a. Scan and e-mail to fax@go to black jackcasino.com
b. Toll Free Fax: 1-866-369-0548
|