I certify that the electronic media record of my transaction held by Palace of Chance Casino shall be used as the final determination to resolve any dispute I may have. I clearly understand it is my sole responsibility, if applicable, to report my financial information to my respective Government, Customs, or Tax jurisdiction. I acknowledge that I have read all the information contained in Palace of Chance Casino license and agree to follow by all the rules, terms, conditions, and agreemets therein and as amended from time to time.

(Please clearly complete ONE form for every Credit Card you have used to deposit If it applies)

After the form is completed and signed, and all necessary documents are attached, fax to: Toll free number: 1-800-551-6087, International: + (506)-256-5502, or send scanned copies to [email protected]. For Customer Service, call: 1-888-262-5515. Please remember to sign the form by hand. * Information Required.

Full Name (as on casino account) * Username *
Address Line #1 *
Address Line #2
City State * Zip/Postal Code *
Country Date of Birth / /
Home Phone * Fax Work Phone
E-mail * Last 4 Digits of Social Security Number: (U.S. Citizens)
Deposit Method(s) used (please mark the ones you have used):

Credit Card: Type of Card      Expiration Date /
        Credit Card Number (account number)
        Name as shown on card:

eCheck ACH: ACH Check ABA Code:
        ACH Bank Account No. ACH Bank Phone:
Debit/ATM: Debit Card Nr. Expiration Date /
       Name as shown on Account:
Neteller: Email address registered in your Neteller account
PrePaidATM: Account Name: Account Number:
Western Union     Wire Transfer EvoCash Central Coin
Other:       

Bank Information please fill out for eventually processing your Wire Transfer withdrawals (withdrawals over $999.99)
Bank Name       Bank Phone
Bank Address 
ABA/Swift #     Account Number Account Name

*Please accept this as authorization for Palace of Chance Casino, to draft the above listed credit card and continue such authorization until I notify Palace of Chance Casino and the bank listed in writing.
Also remember to send us a visible copy of your driver's license or other form of official photo I.D. as well as a copy of each credit card used. In the case of having used another deposit method instead of credit card, please send in a Utility Bill (phone bill, electricity bill).

Signature
(as shown in your ID) ________________________________Date / /