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Credit Card Authorization Form

Personal Information:

Full Name:
Address:
City: State:
ZIP Code: Date of Birth(MM DD YYYY)
Day Phone: Evening Phone:

The Virtual Casino Group - Account Information:

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Website Username Website Username
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Credit Card Information:

Please enter the details of all credit cards you have used or intend to use at the casino.

Enter the first 8 and last 4 digits of your card in the spaces provided.

Card Number Exp. Date (MM/YYYY)
- - XXXX - -
- - XXXX - -
- - XXXX - -
- - XXXX - -

Return with Copies of Your Credit Cards (Front & Back)

For more information on how your purchases will appear on your credit card statement, please feel free to send us an email or contact us via our Live Casino Support.

I Certify...

I certify that the electronic media record of my transaction held by the The Virtual Casino GROUP shall be used as the final determination to resolve any dispute I may have. I acknowledge that I have read all the information contained in the The Virtual Casino GROUP License and agree to abide by all the rules, terms, conditions and agreements therein and as may be amended from time to time.

I also certify that the credit cards listed above have been registered with the The Virtual Casino GROUP and used there with my full knowledge and consent.

Signature: __________________________________________

Date: / /

MMDDYYYY

Please scan and email the signed and completed form to [email protected]