CREDIT CARD AUTHORIZATION FORM

Personal Information:

Full Name:

Address:

State:

City:

Date of Birth:

Zip Code:

Contact Phone:

Country:

Account Information:

User name:

Email:

Credit Card Information:

Enter the first 8 and last 4 digits of your card in the spaces provided.

Card Number

Exp. Date (MM/YYYY)

- -

Exp. Date
(MM/YYYY)

Card Number

Exp. Date (MM/YYYY)

- -

Exp. Date
(MM/YYYY)

Card Number

Exp. Date (MM/YYYY)

- -

Exp. Date
(MM/YYYY)

Card Number

Exp. Date (MM/YYYY)

- -

Exp. Date
(MM/YYYY)

Card Number

Exp. Date (MM/YYYY)

- -

Exp. Date
(MM/YYYY)

Return with Copies of Your Credit Cards (Front & Back)

Scan or take a digital picture of your valid State or Federal ID (i.e. Driver's License or Government Issued ID) along with the credit cards you have used, or plan to use, with our clients (front and back of all cards, including ID's is required).
We will also require a recent utility bill with your printed address on it.
Email all of these copies back, along with this signed form, as soon as possible. You can email copies to support@vegasrushcasino.com.

For more information on how your purchases will appear on your credit card statement, please feel free to send us an email or contact us via our Live Casino Support.

I Certify...

I certify that the electronic media record of my transaction held by the Vegas Rush Casino shall be used as the final determination to resolve any dispute I may have. I acknowledge that I have read all the information contained in the Vegas Rush Casino License and agree to abide by all the rules, terms, conditions and agreements therein and as may be amended from time to time.

I also certify that the credit cards listed above have been registered with the Vegas Rush Casino and used there with my full knowledge and consent.

Date:

Signature: