Majestic Star Casino, LLC - Credit Application

Credit Application Majestic Star Casino

Language

* Indicates field is required

Personal Information

First Name *

Middle Initial

Last Name *

Suffix

AKA

Gender *

Are you applying for someone else? *

First and Last Name *

Country * (US applicants only)

Address *

Years at Address *

Main Phone *

Other Phone

Email Address *

Preferred Contact Method *

Send Mail to

Country

Address *

Statements Sent To *

Social Security # Social Insurance # (SIN) International ID

Date of Birth *

Country of Birth *

Mother's Maiden Name *

Spouse's Name

Driver's License # * **

Expiration * **

Passport #

Country

Expiration

Height * ft in

Weight * lbs

Height * cm

Weight * kg

Hair Color *

Eye Color *

** You must provide a Passport or Driver's License

** International Applicants must provide a Passport or International ID

Trip Information

Referred by (if not referred, enter N/A) *

Player # (if applicable) *

Reservation # *

Arrival Date *

Trip Occasion *

Credit Requested *

Employment Information

Employer / Name of Firm Name of Your Business Previous Employer *

Type of Business *

Number of Years *

Position *

Annual Income *

Business Phone *

Fax *

Country *

Business Address *

New Jersey Gaming Declaration *

Are you a gaming related casino employee, a state officer or employee, member of judiciary or legislature, or an officer of a municipality or county in New Jersey?

Financial Information

Insider of Public Company *

Politically Exposed Person/Relative or Associate *

Marijuana Related Source of Income *

Source of Income *

Investments Held With *

Pension Employer *

Savings Location *

Name of Spouse *

Other Source of Income *

Total Assets *

Source of Wealth *

Estimated Annual Compensation *

Estimated Total Annual Income *

Estimated Tax Bracket *

Estimated Liquid Net Worth *

Estimated Total Net Worth *

Total Amount of Indebtedness *

Source of Funds *

Account #1

Pre-paid debit and credit cards are not valid options.

Branch Country

Financial Institution Type *

Bank Name Credit Union Name *

Bank Routing Number Credit Union Routing Number *

Brokerage Firm *

Account Number Checking Account Number *

Brokerage ID Member ID

Account Type *

* Applicant must be the sole proprietor of this account

Association with Business *

Is Account a Trust? *

Branch Address *

Bank Officer *

Phone *

Account #2

Pre-paid debit and credit cards are not valid options.

Branch Country

Financial Institution Type

Bank Name Credit Union Name

Bank Routing Number Credit Union Routing Number

Brokerage Firm *

Account Number Checking Account Number

Brokerage ID Member ID

Account Type

* Applicant must be the sole proprietor of this account

Association with Business

Is Account a Trust?

Branch Address

Bank Officer *

Phone *

Do you wish to be notified prior to deposit?

Gaming Information Other Casino Credit

Do you have Credit at other casinos? *

Please provide at least one casino where you have credit
If you do not see the casino listed, select 'Other' and enter the casino name in the space provided

Casino *

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Do you have credit at a Caesars Entertainment property utilized within 18 months?

Sign Here

Signature

Date

License Agreement

I certify that I have reviewed all information provided above and state under penalties of perjury this is true and accurate. I certify that I am at least 21 years of age. I authorize Majestic Star Casino, LLC or its agent to conduct such investigations pertaining to the above information as it deems necessary for the approval of my credit limit. In consideration of receiving credit privileges hereunder, I (1) acknowledge that my debt(s) is incurred in the State of Indiana. (2) agree to submit to the jurisdiction of any court of competent jurisdiction in Indiana, State or Federal to enforce this obligation. (3) agree that in the event this extension of credit needs to be placed with an attorney or agency, I will pay all costs of collection, including but not limited to, attorney’s fees, interest at 18% APR or the maximum amount permitted under Indiana law, court costs, filing fees and any bank fees incurred through appeal. A photo copy of this authorization will be considered as effective and valid as the original. In addition, I authorize Majestic Star Casino, LLC in its sole discretion to apply any and all chips, cash, or slot tickets I may redeem first to the reduction of any outstanding credit balance, with the remainder, if any, to be returned to me.

As a condition to being granted marker signing privileges, I agree to sign credit instruments, aka markers or checks (hereinafter "markers") in the amount of the funds (e.g. chips, cash, tokens, etc.) issued to me. Further, I authorize Majestic Star Casino, LLC to complete any of the following information on those markers: (1) name of payee, (2) a date, (3) name, account number, and/or address of any of my banks and financial institutions, (4) electronic encoding of the above and (5) as otherwise authorized by law. The information inserted may be for any account from which I now or may in the future have the right to withdraw funds, regardless of whether that account now exists, and whether I provided the information on the account to Majestic Star Casino, LLC. I agree that each marker I sign is a separate transaction. I REPRESENT THAT AT THE TIME I SIGN ANY MARKER, I HAVE ON DEPOSIT IN ACCOUNTS ON WHICH I AM AN AUTHORIZED SIGNATORY FOR ALL PURPOSES, WITHOUT RESTRICTION, FUNDS SUFFICIENT TO PAY SUCH MARKER UPON DEMAND OR PRESENTMENT.

I understand that this application is required to be prepared in compliance with Indiana Gaming Commission regulations and I may be subject to civil or criminal liability if any material provided by me is willfully false.

Privacy Policy

Click here to view the Majestic Star Casino Privacy Policy.

Click here to view the Privacy Policy for NRT Technologies, Inc. and VisuaLimits, LLC

* I acknowledge that I have read and accept the above privacy policies

Signature

I, the undersigned, hereby authorize and instruct Majestic Star Casino, LLC and its agent NRT Technologies, Inc. and VisuaLimits, LLC. ("NRT") and its affiliates to obtain consumer reports, to contact financial institutions, and to check my consumer credit, employment, bank and gaming history in order to evaluate my credit application as well as to update and/or review my account to provide services requested by me, as necessary or as required by law. I authorize Majestic Star Casino, LLC, NRT or its affiliates to verify such information through any source and to report any information to another casino, excluding credit report data obtained from a credit agency, and to exchange any information with any of the affiliates of the Company. I hereby release and waive, and agree not to bring at any time in the future, any claims or demands against NRT or its affiliates relating to any credit investigation made pursuant to my authorization and instructions herein, including, without limitation, the collection, processing, and transmission of my information and data.

NRT Technologies, Inc. and VisuaLimits, LLC. ("NRT") promotes responsible gambling. By entering my name in the signature field and clicking the "I Accept" button below, I acknowledge that I have read the NRT Technologies, Inc. and VisuaLimits, LLC. Responsible Gaming Policy.

By entering my name in the signature field and clicking the "I Accept" button below, I hereby represent, warrant, and agree that all information provided herein is true and correct, that I am the person for whom I am requesting credit, and that I have read, understand, and agree to be bound by all of the terms herein.

I hereby acknowledge and agree that this Application may be signed electronically and that such electronic signatures shall be deemed an original for all purposes. I represent and warrant that by signing this Application electronically or causing this Application to be signed electronically that I have the authority to do so and that such electronic signature shall be sufficient to bind the respective party under this Application.

Physical Signature

Sign Here

Signature

Date