CREDIT CARD AUTHORIZATION FORM
Please fill out and sign and send this form alongside copies of the following documents to
documents@slotastic.com
1) Color copy of Passport or Driver license of Accountholder (both sides).
2) Color copy of valid Passport or Driver license of the card holder of each authorized credit card
3) Color copy of Authorized Credit Card(s) (both sides).
4) Color copy of a Utility Bill, bank statement or credit card statement, not older than two (2) months
Please note!!! Documents must be scanned at high resolution (300dpi)
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 authorize the use of the following credit card(s) (“Authorized Cards”) for depositing into the above-mentioned Slotastic
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 Slotastic 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
Slotastic account may become inaccessible.
By:
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
AMEX
VISA MASTERCARD
AMEX
