GOLD CIRCLE RACING AND GAMING GROUP

APPLICATION FOR CREDIT CARD FACILITIES ON A TELEPHONE BETTING ACCOUNT


D. CONFIDENTIAL IDENTIFICATION QUESTIONS

Answer any six (6) of the following questions (be sure to answer the
questions that are personal to you and not known by other persons):

1. What is your favourite sport? ____________________________________

2. What is your place of birth? _____________________________________

3. What is your mother's maiden name? _______________________________

4. What is your favourite number? ___________________________________

5. What is your favourite colour? ___________________________________

6. Which school did you last attend? ________________________________

7. What is your wife's maiden name? _________________________________

8. What is your maiden name? ________________________________________

9. What is your favourite animal? ___________________________________

10. What is your favourite car? _____________________________________

E. INDEMNITY

I hereby authorise my respective bank to release any information
required by Gold Circle (Pty) Ltd in order to verify the authenticity
of the account/s stated above and my credit worthiness.

I hereby agree to be solely responsible and liable for any and all
deposits or cash advances made to my telephone betting account on the
above noted credit cards when used in conjunction with my telephone
betting account pin number and any of two (2) of the six (6)
questions answered above. I hereby further acknowledge and agree that
Gold Circle (Pty) Ltd shall not be liable to me for any losses or
damages incurred by me, or any other party, resulting from the use of
these credit cards in conjunction with my telephone betting account.
I further agree to indemnify and hold harmless Gold Circle (Pty) Ltd,
from any and all claims, liabilities, losses or damages whatsoever
incurred from the use of these cards by any third party specifically
including the credit card merchant.




Signature: ____________________________ Date: _______________________


*All references made to Gold Circle (Pty) Ltd specifically include
all former and current employees of the said company.

N.B!  PLEASE ENSURE THAT A CLEAR COPY OF THE FRONT AND BACK OF THE
RELEVANT CREDIT CARDS ARE ATTACHED TO THIS FORM!