CASH YOUR CHIPS CASINO<br>
Credit Card Charge Authorization Form<br>
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Print out this form and fax it to Cash Your Chips Casino, along with a photocopy <br>
of a valid official picture identification card (driver's license, passport,<br>
etc.), your credit card billing statement and a utility bill (phone, electric, <br>
gas, etc.) with your name and address as it appears on your credit card <br>
billing statement and your Cash Your Chips Casino account. <br>
______________________________________________________________________________<br>
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This form confirms your request for payment by Visa/MasterCard.<br>
<br>
Your signature below constitutes your agreement to pay the amount <br>
specified below, and authorizes Cash Your Chips Casino to obtain credit approval <br>
from said credit card company.<br>
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You must sign this agreement as well as the credit card authorization <br>
form below.<br>
<br>
I,__________________________________, hereby authorize Cash Your Chips Casino to <br>
charge my credit card account as  "FireCash/17981"  I affirm that I am at<br>
least 18 years old and that I am legally authorized to use the credit card <br>
account number specified below.  Furthermore, I understand and agree that <br>
the charges specified below are irrevocable and may not be charged-back at<br>
any time in the future.<br>
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SIGNATURE: x______________________________________.  <br>
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Address: ___________________________________________________________.<br>
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Phone #: _____________________.  City: _____________________________.<br>
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Date: _________________    State: _________ Zip/Postal Code: _______.<br>
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Authorization for Deposits to Cash Your Chips Casino Account<br>
<br>
Per my request(s) through their online credit card processing system, I <br>
hereby authorize Cash Your Chips Casino to charge  up to $____________ per month<br>
on the following credit card account<br>
<br>
Credit Card #: __________________________________.<br>
<br>
Expiration Date: _____________<br>
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SIGNATURE: x_____________________________________________.<br>
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Cardholder acknowledges receipt of goods/ services in the amount <br>
( US Dollars) of the total shown herein and agrees to perform the<br>
conditions set forth in their cardholders agreement with the user.<br>
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_________________________________________________________________<br>
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Notary Acknowledgment<br>
<br>
State of ________________<br>
<br>
County of ______________<br>
<br>
On __________________________, before me, the undersigned, a <br>
Notary Public in and for said County and State personally appeared<br>
 ________________________________, personally known to me (or proved<br>
to me on the basis of satisfactory evidence) to be the person whose <br>
name is subscribed to the within Credit Card Authorization Form and <br>
acknowledged to me that said person executed it.<br>
<br>
Witness My Hand and Official Seal<br>
<br>
______________________________________<br>
Notary Public in and for said County and State<br>
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My Commission expires ___________________<br>
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PLEASE SIGN THIS FORM IN BOTH PLACES ABOVE IN FRONT OF A <br>
NOTARY PUBLIC.  <br>
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FAX SIGNED FORM & LEGIBLE PHOTOCOPIES OF PHOTO <br>
IDENTIFICATION CARD, CREDIT CARD STATEMENT & UTILITY BILL. <br>
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Cash Your Chips Casino fax:(509)562-1275<br>
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