Toll free fax from US: 1-888-579-4555
International fax: +506-296-7467
Scan and e-mail to ccprocessing@casinosupportcenter.com

Please also send a copy of your drivers license or other legal photo ID and a copy of the front and back of each credit card used on your account or you are going to use.

AUTHORIZATION FORM

This is to confirm that I, ____________________________________ (name as it appears on card), have authorized Virtual Casino, to process electronic charges to my credit card(s) with the following number(s) via any of their processors. I agree that this authorization and the electronic record of my transactions held by Virtual Casino shall be used as the final determination to resolve any dispute regarding past or future transactions.

Credit Card                 #___________________________ Exp. Date _____/_____      

Credit Card                 #___________________________ Exp. Date _____/_____      

Credit Card                 #___________________________ Exp. Date _____/_____      

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

Address: _________________________________________________________

City        : ______________________ State______________  Zip ____________

Phone  : ____ -_______ - _______       Fax : _____________________________

Email    : ____________________________________

_________________________                                     ____/____/____

Signature                                                                           Date