 Authorization Agreement & Account Verification 

By submitting this signed and dated form, along with the additional information requested, I am authorizing and fully
acknowledging the following:
I am the authorized cardholder and will honor all purchases initiated by me to my account whether completed by
telephone or Internet
I certify that the information provided and supporting documentation is truthful and accurate
I am of age of majority (18 years or older depending on your jurisdiction)
I have read and accepted the terms of use as listed elsewhere on this website
Please enter your information below.
Site Name: Vegas Casino Online
Customer Account ID: Vdawg89

Full Name: Victor Lopez

Phone: 6026143346

Email: vdawv8991@gmail.com

Card Number: 4784993201689858

Card Expiration Date: 05 / 22

Issuing Bank Name: Bancorp

Issuing Bank Phone: 18666794869 Toll free # on back of card

I hereby understand and authorize the above as evidenced by my signature below.

Signature: _________________________________________    Date: _____________________

To make an imprint of your embossed card: -->

1. Place card under box outline
2. Rub pencil very lightly over card
3. Ensure your name, number & expiration date are clear and readable.

Please complete and FAX to: 1-866-702-5078 or EMAIL to: support@vegascasinoonline.eu

Include a photocopy of your picture ID and copies of the front and back of credit card.

  Print this Page...