Personal Information:
Full Name:
Address:
City:   State:  
ZIP Code: Date of Birth:
(MM DD YYYY)
  / /
Day Phone: Evening Phone:  
CAPTAIN JACK CASINO Group - Account Information:
If you have any accounts with our sister casinos, you can speed up future withdrawals by submitting your account name now.
WEBSITE USERNAME WEBSITE USERNAME
CAPTAIN JACK
PLANET 7
RINGMASTER
ROYAL ACE
SILVER OAK
SLOT MADNESS
CAT'S EYE
   
Credit Card Information:
Please enter the details of all credit cards you have used or intend to use at the casino.
Enter the first 8 and last 4 digits of your card in the spaces provided.
CARD NUMBER EXP. DATE (MM/YYYY)
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- XXXX -
-
-
- XXXX -
-
-
- XXXX -
-
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- XXXX -
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Return with Copies of Your Credit Cards (Front & Back)

• Scan or take a digital picture of your valid State or Federal ID (i.e. Driver's License or Government Issued ID) along with the credit cards you have used, or plan to use, with our clients (front and back of all cards, including ID's is required).
• We will also require a recent utility bill or bank statement with your printed address on it.
• Email or fax all of these copies back, along with this signed form, as soon as possible. You can email copies to accounting@captainjackcasino.com . If you prefer to fax, you can send them to any of the Toll Free fax numbers listed at the bottom
of this form.

For more information on how your purchases will appear on your credit card statement, please feel free to send us an email or contact us via our Live Casino Support.

I Certify...

I certify that the electronic media record of my transaction held by the CAPTAIN JACK CASINO GROUP shall be used as the final determination to resolve any dispute I may have. I acknowledge that I have read all the information contained in the CAPTAIN JACK CASINO GROUP License and agree to abide by all the rules, terms, conditions and agreements therein and as may be amended from time to time.

I also certify that the credit cards listed above have been registered with the CAPTAIN JACK CASINO GROUP and used there with my full knowledge and consent.

Signature: ___________________________ Date:
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       MM     DD   YYYY  
Please FAX this form back using our Toll Free FAX number: 1-866-725-1102
You may also scan and email the signed and completed form to accounting@captainjackcasino.com