GOLD CIRCLE RACING AND GAMING GROUP APPLICATION FOR CREDIT CARD FACILITIES ON A TELEPHONE BETTING ACCOUNT 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 1. Card One: VISA ______ MASTER ______ OTHER ______ If Other State Type: _____________________________ Bank: ____________________________________________ Card Number: _____________________________________ Name of Acc. Holder: _____________________________ Expiry Date: ________/________________ 2. Card Two: VISA ______ MASTER ______ OTHER ______ If Other State Type: _____________________________ Bank: ____________________________________________ Card Number: _____________________________________ Name of Acc. Holder: _____________________________ Expiry Date: ________/________________ OFFICE USE ONLY Clearance Code: ____________________ Clearance Code: ____________________ Contact Person at Bank: ____________ Contact Person at Bank: ____________ Details Verified By: _______________ Date: ________________________