Dear Valued client, Old Havana Casino appreciates your business! You must completely fill out this form. Old Havana Casino requires a legible signature on this form.
This form must be accompanied with a photocopy of the front side of your Driver's license and a photocopy of the front and back of your credit card number.
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 future credit card transactions.
Any and all conversations regarding the future purchase of our services via your credit card (s) will be recorded for your and our personal records. Credit Card#_______________________________
Exp. Date _______/_______
Date of Birth: ______/______/______
Player ID# ________________________
Name: _______________________ ____________ ________________________ (First) (Int)
(Last) Address: __________________________________________________________
City: _____________________ State__________________ Zip _____________
Phone # (______) ________ - _______
Fax: (______) ________- _________
Email Address: ____________________________________________________ I ____________________________________, knowing that my account information is private and that it is my responsibility to maintain the privacy of my account, hereby authorize oldhavanacasino.com to charge my credit card(s). We kindly ask you to print out this CREDIT CARD AGREEMENT FORM for your further reference. I further agree that this payment is irrevocable.
Cardholder's Signature: _____________________________________ Date: _____/_____/_______