AGS Slot Machine Player Program Order Form:

1) Fill in your Credit or "online" card information for the purchase 2) Or, you can fill out your name and shipping address below 3) Fill out the form as complete as possible 4) Understand that this is for  amusement  purposes as all casinos advertise on 5) Your  "cvv number"  is needed (3 digit number on back) next to card number 6) Understand that we can ship to you via: emailed or postal mail order     Please read & fill out below:     Credit Card or Check, make your total for;   $30.00 e'mailed   and   $35.00 mailed Check or Money Order payable to: AGS Online PO   Box 1699 Riverton,Wyoming 82501 Check# _______   Postal Money order# __________

Credit Card Information: (Please check one): (Visa)__   (M/C)__  or  (Debit)__         (Am.Exp.)__                        Credit Card # : __________   _________   _________   ___________        cvv# ______ (if available)     Expiation Date: ____   200__                   Cardholder’s Signature : _____________________ Name : ____________________ Address : ____________________ (print clearly) Telephone: (       ) ____ - _____ City : ____________ State/Prov. :__________ e'mail : ______________   Fax#: (___)___-______ Zip : __________                                                                            eFax    (206) 666-3954

For online credit card purchases here > "Online"
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