|
A. TELEPHONE BETTING ACCOUNT DETAILS
|
1. Telephone Betting Account Number: ___________________
|
|
B. PERSONAL DETAILS (TELEPHONE BETTING ACCOUNT HOLDER)
|
| 1. Name: |
_______________________________ |
2. Identity Number: |
_______________________________ |
| 3. Residential Address: |
_______________________________ |
4. Postal Address: |
_______________________________ |
| |
_______________________________ |
|
_______________________________ |
| |
_______________________________ |
|
_______________________________ |
| |
_______________________________ |
|
_______________________________ |
| 5. Telephone Home: |
(__________)____________________ |
6. Telephone Work: |
(__________)____________________ |
| 7. Cell: |
_______________________________ |
8. E-Mail Address: |
_______________________________ |
9. Do you require this application to be handled
in a confidential manner?
Yes 
No
|
|
C. CREDIT CARD DETAILS
|
|
Card 1 :
VISA
MASTER
OTHER
|
Card 2 :
VISA
MASTER
OTHER
|
| If other, state type: |
_______________________________ |
If other, state type: |
_______________________________ |
| Bank: |
_______________________________ |
Bank: |
_______________________________ |
| Card Number: |
_______________________________ |
Card Number: |
_______________________________ |
| Name of Acc. Holder: |
_______________________________ |
Name of Acc. Holder: |
_______________________________ |
| Expiry Date: |
__________/____________________ |
Expiry Date: |
__________/____________________ |