1 Poker Club Credit Card Agreement Form

Dear Valued 1 Poker Club Member,
1 Poker Club appreciates your business! You must completely fill out this form.
1 Poker Club requires a legible signature on this form.

This form must be accompanied with a photocopy of the front side of your Driver’s license or passport and a photocopy of the front and back of your credit card (s) that you have used to deposit. 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 previous or future credit card transactions.

Credit Card(s)       #___________________________ Exp. Date _____/_____

Credit Card(s)       #___________________________ Exp. Date _____/_____

Credit Card(s)       #___________________________ Exp. Date _____/_____

Credit Card(s)       #___________________________ Exp. Date _____/_____

Credit Card(s)       #___________________________ Exp. Date _____/_____

Date of Birth: ______/______/______ Player PID (Username) ________________

Name: ________________________   ________  _________________________
              (First)                (Int.)              (Last)

Address: __________________________________________________

City: _________________ State______________ Zip _______________

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

Email Address: ______________________________________________

I ________________________________________, knowing that my account information is private and it is my responsibility to maintain the privacy of my account, hereby authorize 1 Poker Club to charge my credit card(s) for all deposits made into my account.  I further agree that this payment is irrevocable.

Cardholder’s Signature: _____________________________________

Date: ______/______/_______

Please complete and return all information using any one of the following methods:
a.  Scan and e-mail to fax@prismcasino.com
b.  Toll Free Fax: 1-866-369-0548