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ACCOUNT VERIFICATION / AUTHORIZATION FORM
Please fill out, sign and send this form alongside copies of the following documents to
documents@mailcroco.com
For account verification:
1) Colour copy of Passport or Driving License of account holder (both sides).
2) Colour copy of a Utility Bill, Bank Statement or Credit Card statement, not older than two months.
For credit card(s) authorization:
3) Colour copy of Authorized Credit Card(s) (both sides).
4) Colour copy of Passport or Driving License of the card holder of each Authorized Credit Card.
User Name or Customer Number (Logon)
Date
Account holder Name
Contact Phone 1
Account holder Street Address, Unit/Suite/Apt Number, City, State, ZIP
Contact Phone 2
By placing my signature below, I intend to verify my account and/or authorize the use of the following credit card(s) (“Authorized Cards”) for depositing
into the above-mentioned PlayCroco account. I confirm that I have been authorized to use each of the Authorized Cards listed below and acknowledge
that I must pay all charges incurred by these cards through transactions to my PlayCroco account, regardless of when or by whom the transaction was
authorized. I confirm that you shall be fully protected when honoring any payments from my Authorized Cards. In addition, should any payment from an
Authorized Card for whatever reason whatsoever not be honored, I confirm that you shall be under no liability for any costs, including bank fees, even
though this may mean that my PlayCroco account may become inaccessible.
Signed
Dated
Print Name
Credit Card (1)
Credit Card Number
Expiry Date:
Card billing address:
Name as shown on card
Signature of card holder
Today's date
Credit Card (2)
Credit Card Number
Expiry Date:
Card billing address:
Name as shown on card
Signature of card holder
Today's date
Card Type
Card Type
VISA MASTERCARD
A M E X
VISA MASTERCARD
A M E X
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Completed 2 December 2020

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