I certify that the electronic media record of my transaction held by E-Money Processing Ltd and its affiliates shall be used as the final determination to resolve any dispute I may have. I clearly understand it is my sole responsibility, if applicable, to report my financial information to my respective Government, Customs, or Tax jurisdiction. I acknowledge that I have read all the information contained in their license and agree to follow by all the rules, terms, conditions, and agreements therein and as amended from time to time.

(Please clearly complete ONE form for every Credit Card you have used to deposit If it applies)

After the form is completed and signed, and all necessary documents are attached, fax to: Toll free number: 1-800-847-6197, or send scanned copies to ccprocessing@clubplayercasino.com. For Customer Service, call: 1-800-406-9557. Please remember to sign the form by hand. * Information Required.
Full Name (as on casino account)*
Username*
Address Line #1*
Address Line #2
City
State *
Zip/Postal Code *
Country
Date of Birth / /
Home Phone *
Fax
Work Phone
E-mail *
Last 4 Digits of Social Security Number: (U.S. Citizens)
 
Deposit Method(s) used (please mark the ones you have used):
Credit/Debit Card:  
Type of Card   Expiration Date /
Credit Card Number
(account number)
Name as shown on card:
Neteller:
Email address registered in your Neteller account
PrePaidATM:
Account Name: Account Number:
Other:
 
Wire Transfer: please fill out for eventually processing your Wire Transfer withdrawals
(withdrawals over $999.99)
Bank Name
Bank Phone
Bank Address
ABA/Swift #
Account Number
Account Name

*Please accept this as authorization E-Money Processing Ltd and its affiliates, to draft the above listed credit card and continue such authorization until I notify E-Money Processing Ltd and its affiliates and the bank listed in writing.
Also remember to send us a visible copy of your driver's license or other form of official photo I.D. as well as a copy of each credit card used. In the case of having used another deposit method instead of credit card, please send in a Utility Bill (phone bill, electricity bill).

Signature (as shown in your ID) ________________________________		 Date: