Casino Riches Application Form
I have read and agree to the Casino Riches terms and conditions

To pay via Post or Fax then please complete and print this form:
To pay by Credit/Debit Card via Secure Server please click here: Added Soon

Yes, I wish to join The Casino Cash Affiliate Program immediately. I agree to the terms of conditions and the guarantee that if I do not receive a monthly income of £5,000/$7,500 within the first 6-months I can keep the Online Casino Business for FREE and the pending £400/$600 web site payment will be cancelled.



Please find enclosed the amount of £250/$375 for my Casino Riches domain name and set-up fee in the form of:
Cheque / Postal Order / Bankers Draft / Payable to John Carroll or please debit my Credit/Debit Card

Name:

Address:

State/County: Country:     Post/Zip Code:    

e-mail:  Referral Code No (Optional):

Please make all Cheques / Postal Orders Payable to: John Carroll

                        

                      Added Soon

Card No Issue No (Switch,Solo only):

Visa: Mastercard: Switch: Solo:  Exp Date: Month: Year:

Date://     Signed:_______________________________  

Please Post or Fax your completed form to:
6 St.Augustines Rd, Cheadle Heath, Stockport, Cheshire, England
   Tel/Fax: UK 0161-283-1370       Tel/Fax: International (44) 161-283-1370