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Credit Card Agreement Form
Dear Valued client, 21 Black Jack Online Casino appreciates your business! You must completely fill out this form. 21 Black Jack 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: ____________________ ________ _____________________ 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 21 Black Jack 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 21blackjackonlinecasino.com or epointprocessing.com I further agree that this payment is irrevocable. Cardholder’s Signature: _____________________________________ Date: _____/_____/_______ |