User Name or Account # _________________________________
First Name ____________________________________________ Last Name ____________________________________________
Date of Birth _________ / _________ / ____________________
City _____________________________________________________________ State ______________ Zip_____________________
Please make this my Credit/Debit Card account of record for my future use
Visa Mastercard 16 Digit Embossed Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Expiration Date __ __ / __ __
CVC/CVV Code __ __ __ (3-digit code printed after the credit card number on the back of your card)
This form is required for identification purposes and for the security of your transaction. You may mail or fax the completed form to:
200 Racetrack Road, Building 26
Washington, PA 15301
By providing my Credit/Debit Card information, I hereby take complete responsibility for all deposits made to my account in conjunction with my password.
I authorize credit card cash advances from this card, requested over the phone or web site, be deposited into my Xpressbet Account.
Please attach a photocopy of your credit card.
I have read and agreed to the following terms and conditions:
I confirm that the information I have submitted is complete and accurate.
I agree and acknowledge to be bound by and comply with the Terms of Wagering of Xpressbet and that I am at least 21 years of age.
I further acknowledge that I have completely read, understand and have received a copy of this agreement.
Signature _____________________________________________________________________ Date __________________________