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WINDOWS ONLINE CASINO
 Credit Card Agreement Form
Dear Valued client,
WINDOWS ONLINE CASINO appreciates your business! You must completely fill out this form. WINDOWS ONLINE 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 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:
____________________________ ________ ________________________ 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 WINDOWS 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 either 1) Firepay: SF-CompeCash 2) Gateway: www.gfslonline.com/003 further agree that this payment is irrevocable.
Cardholder’s Signature: ________________________________ Date: _____/_____/_______ Fax
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