TEL AVIV ONLINE CASINO

 

                          Credit Card Agreement Form

 

 

Dear Valued client,

 

TEL AVIV ONLINE CASINO appreciates your business! You must completely fill out this form.

TEL AVIV ONLINE CASINO requires a legible signature on this form.

 

This form must be accompanied with a photocopy of the front side of your Driver’s license and a photocopy of the front and back of your credit card number. Your credit card(s) will only be used for the purpose intended, and will be charged for the specified amount you authorize.  This form will act as a permanent signature on file for any future credit card transactions.

 

Any and all conversations regarding the future purchase of our services via your credit card (s) will be recorded for your and our personal records.

 

Credit Card #___________________________ Exp. Date _____/_____

 

Date of Birth: ______/_____/_____ Player ID# ___________________

 

Name: ____________________   ________  _____________________

                        (First)                        (Int.)                       (Last)

Address: __________________________________________________

 

City: _________________ State______________ Zip ______________

 

Phone # (____)  _______ - _______ Fax: (____) _______- __________

 

Email Address: _____________________________________________

 

I ________________________________________, knowing that my account information is private and that it is my responsibility to maintain the privacy of my account, hereby authorize TEL AVIV ONLINE CASINO to charge my credit card(s) for all deposits made into my account; I understand this charge will appear immediately on my billing statement as “SF-COMPECASH” or as www.gfslonline.com/003 or as http://www.securit-e.ws/ I further agree that this payment is irrevocable.

 

Cardholder’s Signature: _____________________________________

Date: _____/_____/_______