CHIP ORDER FORM

Ready TO WIN??? 

Read INSTRUCTIONS below before completing!!!

NOTICE: You must use the billing address associated with your credit card (i.e, where your statements are mailed!). We will send winnings only to this billing address which we verify with your bank.

Name and Address
*Last Name*
*First Name*
Address
City
State/Province
Zip/Postal Code
Country
*Telephone*

Casino Information
*Acctname*
*Password*

Gold Club Number
*Gold Number* LEAVE BLANK IF NO GOLD ACCOUNT!

E-mail Address
*E-mail Address*

Must enter EXACT email address to receive order

Payment Information
*Amount of Purchase*  $ U.S. Dollars (USD)

Minimum order is $19.95 USD

*Card Number* *Exp Date*
Name of Issuing Bank Card Type
*Exact Name Printed on Card*

Submit Order

I certify that I am authorized to use the credit card above. I authorize you to verify the order with the bank. I give you permission to provide information to the proper authorities in cases of fraud. I understand that this order request may be traced to protect the cardholder from fraud.

WARNING: Please WAIT after clicking below. Your order may take one or two minutes to complete. Do not click more than once.

 

Instructions

To place an order, simply complete the form above. You must have a casino account opened prior to placing an order using this form. Click OPEN ACCOUNT to open an account if you have not already done so. Complete the entire form and your account will be updated with Chips. Make sure your email address is complete. You will receive an automatic email confirmation of your order.

GOLD Club Members: GOLD Club Members need only to complete the areas that have asteriks (i.e. *Last Name*). Enter only the LAST FOUR DIGITS of the credit card used for prior purchases. DO NOT ENTER A GOLD CLUB NUMBER IF YOU HAVE NOT RECEIVED ONE FROM US.

If you have ordered from us in the past and want to become a GOLD Club Member, please send email to webmaster@CasinoMail.com with your full name and address. We will send you a GOLD Club number by email.



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