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Win Here Now - Magic Oasis
Casino
Credit Card Charge Authorization Form
Print out this form and fax it to Magic Oasis Casino, along with a
photocopy of a valid official picture identification card (driver's
license, passport, etc.), your credit card billing statement and a
utility bill (phone, electric, gas, etc.) with your name and address
as it appears on your credit card billing statement and your Magic
Oasis Casino account.
_____________________________________________________________________
This form confirms your request for payment by Visa/MasterCard.
Your signature below constitutes your agreement to pay the amount
specified below, and authorizes Magic Oasis Casino to obtain credit
approval from said credit card company.
You must sign this agreement as well as the credit card authorization
form below.
I, ______________________________, hereby authorize Magic Oasis
Casino to charge my credit card account(s). I affirm that I am at
least 18 years old and that I am legally authorized to use the credit
card account number(s) specified below. Furthermore, I understand and
agree that the charges specified below are irrevocable and may not be
charged-back at any time in the future.
SIGNATURE: x______________________________________.
Address: ___________________________________________________________.
Phone #: _____________________.
Date: _________________
Authorization for Deposits to Magic Oasis Casino Account
Per my request(s) through their online credit card processing system,
I hereby authorize Magic Oasis Casino to charge up to $__________ per
month on the following credit card account(s):
Credit Card #:_________________________
Expiration Date:_______________________
SIGNATURE: x_____________________________________________.
Cardholder acknowledges receipt of goods/ services in the amount
(US Dollars) of the total shown herein and agrees to perform the
conditions set forth in their cardholders agreement with the user.
_________________________________________________________________
Notary Acknowledgment
State of ________________
County of ______________
On __________________________, before me, the undersigned, a
Notary Public in and for said County and State personally appeared
________________________________, personally known to me (or proved
to me on the basis of satisfactory evidence) to be the person whose
name is subscribed to the within Credit Card Authorization Form and
acknowledged to me that said person executed it.
Witness My Hand and Official Seal
______________________________________
Notary Public in and for said County and State
My Commission expires ___________________
PLEASE SIGN THIS FORM IN BOTH PLACES ABOVE IN FRONT OF A NOTARY
PUBLIC.
FAX SIGNED FORM & LEGIBLE PHOTOCOPIES OF PHOTO IDENTIFICATION CARD,
CREDIT CARD STATEMENT & UTILITY BILL.
Magic Oasis Casino US Fax: +1(509)562-1275
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R. North, Indianapolis
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L.Holmes |
$14500 |
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B.DeCaro |
$12600 |
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W.Brooks |
$9200 |
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P.Jones |
$7700 |
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D.Walther |
$7000 |
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$5300 |
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