Credit Card Agreement Form

    Dear Valued Client,

    VEGAS CASINO ONLINE appreciates your business! You must completely fill out this form.

    VEGAS CASINO ONLINE requires a legible signature on 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 to charge my credit card(s). We kindly ask you to print out this CREDIT CARD AGREEMENT FORM  for your further reference.  I further agree that this payment is irrevocable.

    Cardholder’s Signature: _____________________________________

    Date: _____/_____/_______