I certify that the electronic media
record of my transaction held by Palace of Chance Casino 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 Palace
of Chance Casino license and agree to follow by all the rules, terms,
conditions, and agreemets 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: Toll free number: 1-800-551-6087, International: + (506)-256-5502, or send scanned copies to firstname.lastname@example.org. For Customer Service, call: 1-888-262-5515. Please remember to sign the form by hand. * Information Required.