PokerWorld

Instructions for completing form: This form is required for ALL credit card deposits. Print out the form and complete it in full. Next, overnight the original, signed form along with a copy of the front of the credit card, a copy of a signed government issued photo ID (ie. a driver's license, a passport, etc.) and a copy of your most recent credit card statement, to: PokerWorld, 1 Mangrove Way, MBFZ, Freeport, Montego Bay, Jamaica, WI or fax to 1-800-310-8304 / 1-876-953-6181. Forms that are not completely filled out, or do not include clear copies of the credit card, credit card statement or photo ID, will be rejected.

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Please note that all information must be completed and verifiably correct.

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I hereby authorize PokerWorld of Montego Bay, Jamaica to charge the credit card listed below for payments of deposits into my account at PokerWorld. I certify that I am the authorized cardholder and any past or previous charges made by PokerWorld to the account below are valid. I understand charges appear on my statement from PokerWorld's processing company, and appear at this time as www.PokerWorld.com, but may change in the future and can be verified at any time when making a deposit. This authorization is valid until revoked in writing, or until the credit card expiration date occurs, at which time a new authorization form will be required.

Credit Cardholder Name: ________________________________________________________ Signature: ________________________ Dated: ____________(MM / DD / YY) PokerWorld Player Name: _____________________________________________________ E-mail Address:___________________________________________________ Credit Card Billing Address:___________________________________________________ City: ______________ State/Province: ____________ Zip ___________ Country ____________________________ Phone:_________________ Credit Card Type: Visa MasterCard Credit Card #: _________________________________________________________ Credit Card Expiration: Month: _________________ Year: ____________

Please remember to include a copy of both the front and back of the credit card, a signed government issued photo ID, and a copy of your most recent credit card statement. The copies must be clear enough to read all the required information. This process is requested to protect both you and PokerWorld from fraudulent credit card use. We assist fully in the prosecution of credit card fraud.

Internal Use Only:

Approved On:__________________________________ Rejected On: ________________________________________________ Notes:____________________________________Signed:____________

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For a printer friendly version of the form, please click on the icon to the right