Full Name:
Login:
Date of Birth:
Phone:
Email:
Address:
City:
State / Prov:
Zip / Post Code:
Country:
Bank
Name:
Bank Address:
Account Number:
Acct. Holder’s Name:
ABA Routing Nº for wire transfer:
SWIFT/ BIC Code:
BSB Number: (AU/NZ):
Transit ID (Canada):
IBAN Number (Europe):
Alternative Withdrawal Methods:
* Please be informed that a copy of the voided check is needed for bank details validation (optional).
All withdrawal requests must first be reviewed and approved by the casino finance department before being sent for payment.
We record and store all interactions between the customers and the company. This record shall be used in case a dispute arises between the
customer and Eclipse Casino as a guarantee of its successful resolution. Please note that Eclipse Casino is not liable for the accuracy of the
beneficiary details submitted in the form. By placing the signature below, you therefore acknowledge the credibility of the information provided and
agree to act in accordance with the Terms and Conditions.
Signature
Date
Payment Verification Form
Please return the following form along with the identification documents listed below:
1. Photo of ID (back and front in color);
3. Clear photo of the player holding his/her ID (in color);
4. Card verification form for each card used for deposits;
5. Utility bill (or any other official document, containing playerʼs current physical address and full name on it),
issued within 3 (three) months.
Bank/sort code (Canada/UK):
Documents to be submitted via email: verification@eclipsecasino.com
2. Photo of the credit card used (back and front in color). Company requires only first 6 and last 4 digits,
expiry date and card holder's name on the front to verify it in the system with the card holderʼs signature on
the back;
ACH Routing Nº for wire transfer:
