KEMBAR78
Card Authentication | PDF | Credit Card | Payments
Scribd
Upload
231 views1 page

Card Authentication

This document is a form for customers to fill out to authenticate their credit card for deposits with Rich Palms Casino. It requests the customer provide their personal information like name, address, date of birth, email, and phone number. It also asks for the first 6 and last 4 digits of the credit card number and the expiration date. By submitting the form, the customer confirms they are over 18 and the account is registered with their personal information, and that they are the legitimate holder of the card being used and take responsibility for any purchases made with it at Rich Palms Casino.

Uploaded by

Neto Ducer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
231 views1 page

Card Authentication

This document is a form for customers to fill out to authenticate their credit card for deposits with Rich Palms Casino. It requests the customer provide their personal information like name, address, date of birth, email, and phone number. It also asks for the first 6 and last 4 digits of the credit card number and the expiration date. By submitting the form, the customer confirms they are over 18 and the account is registered with their personal information, and that they are the legitimate holder of the card being used and take responsibility for any purchases made with it at Rich Palms Casino.

Uploaded by

Neto Ducer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Rich Palms asi Card Authentication

By filling this form you, the Customer, acknowledge that all the information presented is accurate and up to date. In turn, we, the
Casino, ensure that your personal information is secure and protected, and won’t be shared with any third-party organizations.

Please, fill in the form, capture it with the current date and signature, and send to faxback@richpalms.com

First Name: Phone:

Last Name: Country:

Username: City:

Date of Birth: State: Zip Code:

Email: Address:

Please, choose the type of card you have used for depositing with Rich Palms Casino

● VISA MASTERCARD AMEX DISCOVER CARD

Fill in the first 6 and the last 4 digits of the card number, and the expiry date

Card number: Expiration date:

Please make sure that you enclose the card’s photo in color, with cardholder’s full name, first 6 and last 4 digits of the card
number, and the expiry date clearly visible.

CreditCard BANK

XXX

4141 59XX XXXX 9793 Hide Your CVV code

Date of issue

19 / 11 / 2009

By submitting this form you hereby confirm that:

You are of 18+ years old and this account was registered of your own free will, using your personal information. You give
your consent for processing your personal data.
You are the legitimate holder of the card used and take on the obligation for all the purchases made with Rich Palms
Casino.
ha a h Rich Palms asi s a a h m

Date: Signature:

You might also like