CREDIT APPLICATION * Indicates field is required Personal Information PERSONAL INFORMATION First Name * Middle Name Last Name * Suffix Suffix Suffix Select a suffix JR SR II III IV AKA Gender * Gender Gender Select a sex Female Male Country * United States Country Select a country Abkhazia Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Ashmore and Cartier Islands Australia Australian Antarctic Territory Austria Azerbaijan Bahamas, The Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Sovereign Base Areas British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People's Republic of China, Republic of (Taiwan) Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the (Congo Kinshasa) Congo, Republic of the (Congo Brazzaville) Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea, Democratic People's Republic of (North Korea) Korea, Republic of (South Korea) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Nagorno-Karabakh Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories (Gaza Strip and West Bank) Palmyra Atoll Panama Papua New Guinea Paraguay Peru Peter I Island Philippines Pitcairn Islands Poland Portugal Pridnestrovie (Transnistria) Puerto Rico Qatar Queen Maud Land Reunion Romania Ross Dependency Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Georgia and the South Sandwich Islands South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Address * Years at Address City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Main Phone * Main Phone Type Main Phone Type Main Phone Type Select a phone type Home Cell Other Phone Other Phone Type Other Phone Type Other Phone Type Select a phone type Home Cell Email Address Preferred Contact Method Preferred Contact Method Preferred Contact Method Select a contact method Main Phone Other Phone Email Mail None Send Mail to Mail to Mail to Select a mailing address Business Home None Other Social Security # * Date of Birth * Mother's Maiden Name * Spouse's Name Driver's License # ** State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Expiration Passport # ** Country Passport Issuing Country Passport Issuing Country Select a country Abkhazia Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Ashmore and Cartier Islands Australia Australian Antarctic Territory Austria Azerbaijan Bahamas, The Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Sovereign Base Areas British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People's Republic of China, Republic of (Taiwan) Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the (Congo Kinshasa) Congo, Republic of the (Congo Brazzaville) Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea, Democratic People's Republic of (North Korea) Korea, Republic of (South Korea) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Nagorno-Karabakh Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories (Gaza Strip and West Bank) Palmyra Atoll Panama Papua New Guinea Paraguay Peru Peter I Island Philippines Pitcairn Islands Poland Portugal Pridnestrovie (Transnistria) Puerto Rico Qatar Queen Maud Land Reunion Romania Ross Dependency Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Georgia and the South Sandwich Islands South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Expiration ** You must provide a Passport or Driver's License Trip Information TRIP INFORMATION Referred by Player # (if applicable) Arrival Date * Trip Occasion Trip Occasion Trip Occasion Casino Event Chinese New Year Christmas Columbus Day Concert Grand Opening Hotel Event July 4th Labor Day March Madness Mardi Gras Memorial Day MLK Day New Years Pool Openings Presidents Day Super Bowl Thanksgiving Vacation Weekend Getaway Credit Requested: Minimum $1000 * $ Employment Information EMPLOYMENT INFORMATION Click if retired RETIRED Employer / Name of Firm * Type of Business * Number of Years * Position * Annual Income * $ Business Phone * Fax Country United States Business Country Select a country Abkhazia Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Ashmore and Cartier Islands Australia Australian Antarctic Territory Austria Azerbaijan Bahamas, The Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Sovereign Base Areas British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People's Republic of China, Republic of (Taiwan) Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the (Congo Kinshasa) Congo, Republic of the (Congo Brazzaville) Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea, Democratic People's Republic of (North Korea) Korea, Republic of (South Korea) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Nagorno-Karabakh Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories (Gaza Strip and West Bank) Palmyra Atoll Panama Papua New Guinea Paraguay Peru Peter I Island Philippines Pitcairn Islands Poland Portugal Pridnestrovie (Transnistria) Puerto Rico Qatar Queen Maud Land Reunion Romania Ross Dependency Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Georgia and the South Sandwich Islands South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Business Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code FINANCIAL INFORMATION Financial Information Primary Bank Information ACCOUNT #1 Pre-paid debit and credit cards are not valid options. Branch Country United States Branch Country Select a country Abkhazia Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Ashmore and Cartier Islands Australia Australian Antarctic Territory Austria Azerbaijan Bahamas, The Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Sovereign Base Areas British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People's Republic of China, Republic of (Taiwan) Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the (Congo Kinshasa) Congo, Republic of the (Congo Brazzaville) Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea, Democratic People's Republic of (North Korea) Korea, Republic of (South Korea) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Nagorno-Karabakh Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories (Gaza Strip and West Bank) Palmyra Atoll Panama Papua New Guinea Paraguay Peru Peter I Island Philippines Pitcairn Islands Poland Portugal Pridnestrovie (Transnistria) Puerto Rico Qatar Queen Maud Land Reunion Romania Ross Dependency Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Georgia and the South Sandwich Islands South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Financial Institution Type * Select type... Select type... Bank Brokerage Credit Union Bank Name * Bank Routing Number * Click here to see Routing Number example Account Number * Account Type * Personal Select bank account type... Personal Business Click if sole proprietorship Is Account a Trust? * Select... Select... Select... No Yes Branch Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Bank Officer Phone Secondary Bank Information ACCOUNT #2 Pre-paid debit and credit cards are not valid options. Branch Country United States Branch Country Select a country Abkhazia Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Ashmore and Cartier Islands Australia Australian Antarctic Territory Austria Azerbaijan Bahamas, The Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Sovereign Base Areas British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People's Republic of China, Republic of (Taiwan) Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the (Congo Kinshasa) Congo, Republic of the (Congo Brazzaville) Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea, Democratic People's Republic of (North Korea) Korea, Republic of (South Korea) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Nagorno-Karabakh Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories (Gaza Strip and West Bank) Palmyra Atoll Panama Papua New Guinea Paraguay Peru Peter I Island Philippines Pitcairn Islands Poland Portugal Pridnestrovie (Transnistria) Puerto Rico Qatar Queen Maud Land Reunion Romania Ross Dependency Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Georgia and the South Sandwich Islands South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Financial Institution Type Select type... Select type... Bank Brokerage Credit Union Bank Name Bank Routing Number Click here to see Routing Number example Account Number Account Type Personal Select bank account type... Personal Business Click if sole proprietorship Is Account a Trust? Select... Select... Select... No Yes Branch Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Bank Officer Phone Gaming Information Other Casino Credit GAMING INFORMATION OTHER CASINO CREDIT Do you have Credit at other casinos? * Do you have Credit at other casinos? Do you have Credit at other casinos? No Yes LICENSE AGREEMENT I represent and warrant that I am applying for credit from Casino One Corporation ("Lumiere Place") for my own personal gaming purposes. Casino credit is not intended to be used as a revolving credit line; it is strictly a privilege for gaming purposes and must be utilized in that manner. If the credit line is not utilized in accordance with the terms listed, management reserves the right to reduce or revoke the credit limit. I certify that I have reviewed all of the information provided above and that it is true and accurate. I will advise Lumiere Place if any of this information changes. I authorize Lumiere Place to obtain information regarding my accounts with the financial institutions listed or subsequently discovered, to request information from any credit reporting agency and to exchange pertinent information with others who may properly receive this information. I release and agree to hold harmless Lumiere Place, the financial institutions and/or reporting agencies from any and all liability for their use of the said information about me so provided or exchanged. I agree that I am liable for the repayment of any and all credit that is extended to me by Lumiere Place. I waive any right, statutory or otherwise, to stop payment on any instrument issued in connection to any credit extended to me. I agree that the Lumiere Place may, at its discretion, apply any chips, slot tickets or jackpots presented by me to any outstanding balance due on my credit account with the remainder, if any, to be returned to me. I agree that this application and all credit issued pursuant thereto will be governed, construed and interpreted pursuant the laws of Missouri. I authorize Lumiere Place to collect the funds due on any check that I write, including counter checks, drawn on any of my bank accounts, listed or not. If I do not fulfill any of the above obligations, I hereby authorize the Lumiere Place to provide the above information regarding me and my credit, employment, and account history to any agent, successor, or assignee for collection. I agree that Lumiere Place may litigate any dispute involving the credit line, the debt, or the payee in any court, state or federal, in Missouri. Should legal action be taken to collect an outstanding balance, I agree to pay all costs of collection, including reasonable attorneys' fees. PRIVACY POLICY Click here to view the Privacy Policy for Lumiere Place. Click here to view the Privacy Policy for NRT Technologies, Inc. and VisuaLimits, LLC AGREE * I acknowledge that I have read and accept the above privacy policies SIGNATURE I, the undersigned, hereby authorize and instruct Lumiere Place and its agent NRT Technologies, Inc. and VisuaLimits, LLC. ("NRT") and its affiliates to obtain consumer reports, to contact financial institutions, and to check my consumer credit, employment, bank and gaming history in order to evaluate my credit application as well as to update and/or review my account to provide services requested by me, as necessary or as required by law. I authorize Lumiere Place, NRT or its affiliates to verify such information through any source and to report any information to another casino, excluding credit report data obtained from a credit agency, and to exchange any information with any of the affiliates of the Company. I hereby release and waive, and agree not to bring at any time in the future, any claims or demands against NRT or its affiliates relating to any credit investigation made pursuant to my authorization and instructions herein, including, without limitation, the collection, processing, and transmission of my information and data. NRT Technologies, Inc. and VisuaLimits, LLC. ("NRT") promotes responsible gambling. By entering my name in the signature field and clicking the "I Accept" button below, I acknowledge that I have read the NRT Technologies, Inc. and VisuaLimits, LLC. Responsible Gaming Policy. By entering my name in the signature field and clicking the "I Accept" button below, I hereby represent, warrant, and agree that all information provided herein is true and correct, that I am the person for whom I am requesting credit, and that I have read, understand, and agree to be bound by all of the terms herein. I hereby acknowledge and agree that this Application may be signed electronically and that such electronic signatures shall be deemed an original for all purposes. I represent and warrant that by signing this Application electronically or causing this Application to be signed electronically that I have the authority to do so and that such electronic signature shall be sufficient to bind the respective party under this Application. PHYSICAL SIGNATURE CLICK HERE IF VISUALLY IMPAIRED Sign Here Use your mouse or touchscreen to sign above CLEAR Signature Date I ACCEPT ncc