Dear Valued client,

ONLINE CASINO TO PLAY ROULETTE appreciates your business!

You must completely fill out this form.

ONLINE CASINO TO PLAY ROULETTE 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) (Initial) (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 ONLINE CASINO TO PLAY ROULETTE 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 Number:
(in the USA) - 866-413-6261
all others: 506-280-7579