I certify that the electronic media record of my transaction(s) held by Vegas Lucky 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 Vegas Lucky Casino license 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, signed, and all necessary documents are attached, send scanned copies to cashier@vegaslucky.com. For Customer Support, call: 1-866-504-3063. Please remember to hand sign the form. IT IS VERY IMPORTANT THAT YOU SEND THE DOCUMENTS USING THE SUBJECT: "SECURITY FORM", otherwise we will not be able to guarantee the receipt of your email. * Information Required.

Full Name (as on casino account) *
Login *
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: Account Number: Account E-mail:
Click2Pay: Account Number: Account E-mail:
Other:       

Wire Transfer: please fill out in order to process 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 Vegas Lucky Casino, to draft the above listed credit card and continue such authorization until I notify Vegas Lucky Casino 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 (front and back) 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:
*Please e-mail this form to cashier@vegaslucky.com or Fax it to: 011 (507) 306-1220
NOTE: Emailing the form & documentation is our preferred method as it guarantees
the copies are clear & readable.