I certify that the electronic media record of my transaction held by Play United Network of Casinos shall be used as the final determination to resolve any dispute I may have. I clearly understand it is my sole responsibility, if applicable, to report my financial information to my respective Government, Customs, or Tax jurisdiction. I acknowledge that I have read all the information contained in Play United Network of Casinos licenses and agree to follow by all the rules, terms, conditions, and agreements therein and as amended from time to time.

(Please clearly complete ONE form for every Credit Card you have used to deposit If it applies)

After the form is completed and signed, and all necessary documents are attached, fax to: N. America toll-free number (fax/telephone): (1) 866-456-6439 OR International: + (800)-761-1303, or send scanned copies to support@flexicasino.com. Please remember to hand sign the form. * Information Required.

Full Name (as on casino account) *
Username *
Address Line #1 *
Address Line #2
City State * Zip/Postal Code *
Country Date of Birth / /
Home Phone * Fax Work Phone
E-mail * Last 4 Digits of Social Security Number: (U.S. Citizens)
Deposit Method(s) used (please mark the ones you have used):

Credit/Debit Card: Type of Card

Expiration Date

 /
 
Credit Card Number (account number) - - -
  Name as shown on card:
eCheck ACH: ACH Check ABA Code:
        ACH Bank Account No. ACH Bank Phone:
Neteller: Email address registered in your Neteller account
All Other Methods:       

Wire Transfer: please fill out for eventually processing your Wire Transfer withdrawals (withdrawals over $999.99)
Bank Name       Bank Phone
Bank Address 
ABA/Swift #     Account Number Account Name

*Please accept this as authorization for Play United Network of Casinos, to draft the above listed credit card and continue such authorization until I notify Play United Network of Casinos and the bank listed in writing.
Also remember to send us a visible copy of your driver's license or other form of official photo I.D. as well as a copy of each credit card used. In the case of having used another deposit method instead of credit card, please send in a Utility Bill (phone bill, electricity bill).

Signature (as shown in your ID) ________________________________		 Date: