Rome Casino Credit Card Purchase and Authorization Form

Credit Card Information

Username at RomeCasino.com:

Credit Card company name:

Credit Card company phone #:

Credit Card number:

Expiration Date:

The 3-4 digit code:

Name as it appears on Credit Card:

Line 1 of Card:

Line 2 (normal on corp. cards) of Card:

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Billing address associated with the Credit Card

Address:

City:

State:

Zip:

Phone:

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Amount to be charged

USD$:

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I, ________________________________, hereby authorize RomeCasino.com to charge the above
mentioned amount and other amounts deposited by this credit card. No refunds will be issued if any
of our Acceptable Use Policies are violated. Fax back to 1-703-991-8879 or scan and email to:
support@romecasino.com



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Authorized credit card signature

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Date