Personal Information:
| Full Name: | ||||
| Address: | ||||
| City: | State: | |||
| ZIP Code: | Date of Birth(MM DD YYYY) | |||
| Day Phone: | Evening Phone: | |||
Palace of Chance Group – Account Information:
If you have any accounts with our sister casinos, you can speed up future withdrawals by submitting your account name now.
| Website | Username | Website | Username |
|---|---|---|---|
| Club Player | Ruby Slots | ||
| CoolCat | Slots of Vegas | ||
| Dreams | Vegas Strip | ||
| Palace of Chance | Virtual | ||
| Prism | Wild Vegas |
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)
- Scan or take a digital picture of your valid State or Federal ID (i.e. Driver’s License or Government Issued ID) along with the credit cards you have used, or plan to use, with our clients (front and back of all cards, including ID’s is required).
- We will also require a recent utility bill with your printed address on it.
- Email all of these copies back, along with this signed form, as soon as possible. You can email copies to documents@palaceofchance.com
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 Palace of Chance 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 Palace of Chance 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 Palace of Chance GROUP and used there with my full knowledge and consent.
Signature: __________________________________________
Date: / /
Please scan and email the signed and completed form to documents@palaceofchance.com