Faxback Form

Please fill out the form below, click the print button, sign, then fax to +1 866 896 3177 or see alternate Toll Free numbers listed on the support page. Be sure to include copies of your identification, credit card used (front and back) 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 Portofino 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 Portofino 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), scan and e-mail to PFC@wagerjunction.com

Player ID (as on account)
Full Name (as on account)
Address Line #1
Address Line #2
City State
Country
Home Phone   Fax
Work Phone E-mail
Zip/Postal Code Other E-mail
Date of Birth   
                                 
 PURCHASE METHOD
Type of Method:
Credit Card / Account Number:
IF CARD METHOD PLEASE PROVIDE THE FOLLOWING:  
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 Portofino Casino to draft the above listed credit card and continue such authorization until I notify Portofino Casino and the bank listed in writing.

By this I authorize Portofino Casino to charge my card as I requested also I authorize all purchases made by me at Portofino Casino and I understand that the charges will appear on my credit card statement as Aquapay. I further agree that this payment is final and irreversible

Signature: _________________________ Date: / /