Instructions:

  1. Print out this page.
  2. Person who's name is on the credit card used must fill in the form, Sign & Date.
  3. Obtain clear photocopies of both sides of the associated credit card and the front side of the
    driver's license or equivalent picture identification of the person whose name is on the card used.
  4. Fax all pages to 1-877-443-7008, Attention: Accounting.

If you need assistance, please open a help desk ticket, or email support@bingocs.com or call toll free 1-800-321-7621.

Credit Card Authorization Form

Credit Card:                                                                  Exp. Date:           /                    

Date of Birth (mm/dd/yy):          /          /          

Name:(First)                                                                   (Int.):                  (Last):                                                             

Address:                                                                                                                         

Address:                                                                                                                         

City:                                                              State:                                                                  

Zip (Postal code):                                                                    Country:                                                             

Phone: (          )                                                                    Fax(optional): (          )                                                             

I hereby acknowledge I used the above credit card at World Wide Vegas for the amount of $                     . I agree to pay the above total amount according to the card issue agreement for the associated card (merchant agreement if credit voucher).

Cardholder's Signature:                                                             Date: