Dear Valued client,

Play Las Vegas Online Casino appreciates your business! You must completely fill out this form.

This form must be accompanied with a photocopy of the front side of your Driver’s license and a photocopy of the front and back of your credit card number. 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 future credit card transactions.

Any and all conversations regarding the future purchase of our services via your credit card (s) will be recorded for your and our personal records.

Credit Card #___________________________ Exp. Date _____/_____

Date of Birth: ______/_____/_____ Player ID# ___________________

Name: ____________________ ________ _____________________
(First) (Int) (Last)

Address: __________________________________________________

City: _________________ State______________ Zip ______________

Phone # (____) _______ - _______ Fax: (____) _______- __________

Email Address: _____________________________________________

I ____________________________________, knowing that my account information is private and that it is my responsibility to maintain the privacy of my account, hereby authorize Play Las Vegas Online Casino to charge my credit card(s) for all deposits made into my account; I understand this charge will appear immediately on my billing statement as play-las-vegas-online-casino.com or epointprocessing.com I further agree that this payment is irrevocable.

Cardholder’s Signature: _____________________________________

Date: _____/_____/_______