Third Party Credit Card Authorization and Consent Form

I, (CARD HOLDER’S FULL

NAME) (CARD HOLDER’S ID NUMBER) hereby

authorize (PLAYER FULL NAME)

(ID NUMBER) to use and to charge my credit card for the

purpose of purchasing the services of online casino games on the Following site

www. .com.

Type of Card  Visa  MasterCard  American Express

Last four Credit Card numbers

Expiration Date:

Name of Cardholder:

Credit Card billing address:

Authorized Signature of Cardholder

*to be signed only by the Cardholders

Signing this document, I acknowledge and accept full responsibility that this Credit Card
may be used to make deposits to the above player’s account and agree to honor and
abide by the terms of payment as outlined in www. .com
Terms and Conditions section.

Signature: Date: