Belterra Casino - Credit Application

Credit Application Belterra Casino

* Indicates field is required

Personal Information

First Name *

Middle Name

Last Name *

Suffix

AKA

Gender *

Are you applying for someone else? *

First and Last Name *

Country *

Address *

Years at Address *

Main Phone *

Other Phone

Email Address *

Preferred Contact Method *

Send Mail to

Country

Address *

Statements Sent To *

Social Security # Social Insurance # (SIN) International ID

Date of Birth *

Country of Birth *

Mother's Maiden Name *

Spouse's Name

Driver's License # * **

Expiration * **

Passport #

Country

Expiration

Height * ft in

Weight * lbs

Height * cm

Weight * kg

Hair Color *

Eye Color *

** You must provide a Passport or Driver's License

** International Applicants must provide a Passport or International ID

Trip Information

Referred by (if not referred, enter N/A) *

Player # (if applicable) *

Reservation # *

Arrival Date *

Trip Occasion *

Credit Requested *

Employment Information

Employer / Name of Firm Name of Your Business Previous Employer *

Type of Business *

Number of Years *

Position *

Annual Income *

Business Phone *

Fax *

Country *

Business Address *

New Jersey Gaming Declaration *

Are you a gaming related casino employee, a state officer or employee, member of judiciary or legislature, or an officer of a municipality or county in New Jersey?

Financial Information

Insider of Public Company *

Politically Exposed Person/Relative or Associate *

Marijuana Related Source of Income *

Source of Income *

Investments Held With *

Pension Employer *

Savings Location *

Name of Spouse *

Other Source of Income *

Total Assets *

Source of Wealth *

Estimated Annual Compensation *

Estimated Total Annual Income *

Estimated Tax Bracket *

Estimated Liquid Net Worth *

Estimated Total Net Worth *

Total Amount of Indebtedness *

Source of Funds *

Account #1

Pre-paid debit and credit cards are not valid options.

Branch Country

Financial Institution Type *

Bank Name Credit Union Name *

Bank Routing Number Credit Union Routing Number *

Brokerage Firm *

Account Number Checking Account Number *

Brokerage ID Member ID

Account Type *

* Applicant must be the sole proprietor of this account

Association with Business *

Is Account a Trust? *

Branch Address *

Bank Officer *

Phone *

Account #2

Pre-paid debit and credit cards are not valid options.

Branch Country

Financial Institution Type

Bank Name Credit Union Name

Bank Routing Number Credit Union Routing Number

Brokerage Firm *

Account Number Checking Account Number

Brokerage ID Member ID

Account Type

* Applicant must be the sole proprietor of this account

Association with Business

Is Account a Trust?

Branch Address

Bank Officer *

Phone *

Instant Bank Account Verification –
Speeds up approval!

If you want to speed up the approval process, click the Instant Verification button to complete the requested information and we will receive a read-only verification of your bank account status.

This is safe, secure, encrypted, and fast
You will need: bank login and bank account information
No bank login information is retained by the casino

Click on the accounts you would like to verify then click Proceed

Bank Name:
Routing Number:
Account Number:

Bank Name:
Routing Number:
Account Number:

The errors listed above need to be fixed before submitting Instant Bank Verifications for the selected accounts. Please return to the application and fix the errors

The following errors need to be fixed before submitting an Instant Bank Verification.

Please return to the application and fix the errors

Do you wish to be notified prior to deposit?

Gaming Information Other Casino Credit

Do you have Credit at other casinos? *

Please provide at least one casino where you have credit
If you do not see the casino listed, select 'Other' and enter the casino name in the space provided

Casino *

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Casino

Country

Limit

Do you have credit at a Caesars Entertainment property utilized within 18 months?

Sign Here

Signature

Date

License Agreement

I hereby authorize Belterra Casino Resort to investigate my credit record and to furnish information concerning such credit record to credit reporting agencies and others who may properly receive this information.

I acknowledge that I am responsible for the payment of credit issued. And I waive any right, statutory or otherwise, to stop payment on any instruments issued in connection with credit issued to me. I agree to submit to the jurisdiction of any court, federal or state, in Indiana should legal action be taken to collect any outstanding balance and agree to pay all cost of collections including attorney fees. I hereby waive any defense to any such action based on lack of personal jurisdiction or improper venue.

I certify that I have reviewed all of the information provided above and that it is true and accurate. I authorize Belterra Casino Resort to conduct such investigations pertain to the above information as it deems necessary for the approval of my credit limit. I am aware that this application is required to be prepared by the regulations of the Indiana Gaming Commission and I may be subject to civil or criminal liability of any material information provided by me is willfully false. I hereby authorize Belterra Casino Resort within its sole discretion, to apply any and all chips I may redeem to the reduction of any outstanding credit balance, with the remainder, if any, to be returned to me.

Privacy Policy

Click here to view the Privacy Policy for Belterra Casino.

Click here to view the Privacy Policy for NRT Technologies, Inc. and VisuaLimits, LLC

* I acknowledge that I have read and accept the above privacy policies

Signature

I, the undersigned, hereby authorize and instruct Belterra Casino and its agent NRT Technologies, Inc. and VisuaLimits, LLC. ("NRT") and its affiliates to obtain consumer reports, to contact financial institutions, and to check my consumer credit, employment, bank and gaming history in order to evaluate my credit application as well as to update and/or review my account to provide services requested by me, as necessary or as required by law. I authorize Belterra Casino, NRT or its affiliates to verify such information through any source and to report any information to another casino, excluding credit report data obtained from a credit agency, and to exchange any information with any of the affiliates of the Company. I hereby release and waive, and agree not to bring at any time in the future, any claims or demands against NRT or its affiliates relating to any credit investigation made pursuant to my authorization and instructions herein, including, without limitation, the collection, processing, and transmission of my information and data.

NRT Technologies, Inc. and VisuaLimits, LLC. ("NRT") promotes responsible gambling. By entering my name in the signature field and clicking the "I Accept" button below, I acknowledge that I have read the NRT Technologies, Inc. and VisuaLimits, LLC. Responsible Gaming Policy.

By entering my name in the signature field and clicking the "I Accept" button below, I hereby represent, warrant, and agree that all information provided herein is true and correct, that I am the person for whom I am requesting credit, and that I have read, understand, and agree to be bound by all of the terms herein.

I hereby acknowledge and agree that this Application may be signed electronically and that such electronic signatures shall be deemed an original for all purposes. I represent and warrant that by signing this Application electronically or causing this Application to be signed electronically that I have the authority to do so and that such electronic signature shall be sufficient to bind the respective party under this Application.

Physical Signature

Sign Here

Signature

Date

Credit Application Belterra Casino

Personal Information

Trip Information

Employment Information

Financial Information

Account #1

Account #2

Instant Bank Account Verification –
Speeds up approval!

Select an Account

You are currently verifying :

Gaming Information Other Casino Credit

License Agreement

Privacy Policy

Signature

Physical Signature

Credit Application Belterra Casino

Personal Information

Trip Information

Employment Information

Financial Information

Account #1

Account #2

Instant Bank Account Verification – Speeds up approval!

Select an Account

You are currently verifying :

Click on the accounts you would like to verify then click Proceed

You are currently verifying :

Please complete all steps of the verification process.

When finished click the Finish button below.

Gaming Information Other Casino Credit

License Agreement

Privacy Policy

Signature

Physical Signature

Instant Bank Account Verification –
Speeds up approval!