Mailing Information (Print Clearly)

Full Name:                                         DOB:  /  /  .

                    Last                     First                       Middle

Address:                                   Phone:              

City:                                   State:     Zip:        

Spouse's Name:                                     DOB:  /  /  .

Employer/Firm Name:                        Position:           

Address:                                   Phone:              

City:                                   State:      Zip:       

Mail To Be Received At:   Business:       Residence:     

E-mail:                                    Fax:                

Credit  Information:  At least one bank account is required to process your Casino Credit Application.

I Have Established Credit At the Following Casinos:

                Limit:$                          Limit:$       

                Limit:$                          Limit:$       

Bank#1:                                                        

Address:                                                       

City:                                   State:      Zip:       

ABA No.:                  Account No.:                         

Type Of Acct.: Business:     Personal:     Phone:              

Bank Officer:                 Position:                        

Bank#2:                                                        

Address:                                                       

City:                                   State:      Zip:       

ABA No.:                  Account No.:                         

Type Of Acct.: Business:     Personal:     Phone:              

Bank Officer:                 Position:                        

 Maximum Credit Requested: $          

 Front Money you usually bring: $          

Personal Description:

Sex:      HT:         WT:         Eyes:          Hair:         

SSN:    -   -      Drivers License:                 State:     

Signature:                            Date:  /  /   

 By my signature, I authorize any casino to check my credit ratings.

Sign and Fax to Casino Junket Club at 678-580-1651

Or mail to: Casino Junket Club, 10945 State Bridge Rd STE 401-336, Alpharetta, GA  30022-5676.

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