Superior Casino - Personal Verification Faxback Form

By simply filling out the following form, we are able to verify your details and eliminate any fraudulent activities. Once we have received and approved your Personal Verification Form, you will start receiving more benefits, plus your withdrawals will be approved without delay. Please fill out the form below, click the print button, sign, then email scanned copies to or contact support for alternate email addresses. Be sure to include scanned copies of your identification (front and back), credit card used (front and back of all cards utilized at the casino, even failed attempts) if applicable and a copy of your recent utility bill. This information is used to ensure payment goes to the proper recipient and to prevent fraud.

I certify that the electronic media record of my transaction held by Superior 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 the Superior Casino license and agree to follow by all the rules, terms, conditions, and agreements therein and as amended from time to time.

Please complete one form for each credit card you have used (i.e., multiple forms), fax and e-mail to

Player ID (as on account)
Full Name (as on account)
Address Line #1
Address Line #2
City State
Home Phone   Fax
Work Phone E-mail
Zip/Postal Code Other E-mail
Date of Birth   
Type of Method:
Credit Card / Account Number:
Expiration Date:
Name as shown on Card:
Bank Name:

Also remember to send a visible copy of your driver's license or proper identification and a legible copy of both sides of your credit card as well as a recent utility bill.

Please accept this as authorization for Superior Casino to draft the above listed credit card and continue such authorization until I notify Superior Casino and the bank listed in writing.

By this I authorize Superior Casino to charge my card as I requested also I authorize all purchases made by me at Superior Casino and I understand that the charges will appear on my credit card statement as described in the confirmation emails I received for each purchase. I further agree that this payment is final and irreversible

Signature: _________________________ Date: / / All Rights Reserved 2007