Form Lv Cr300 – Fill Out and Use This PDF

CASINO CREDIT • (800) 634-3403 • FAX: (702) 386-8306

CREDIT REQUEST FORM

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Last Name, First Name, M.I. (Primary)				Secondary Party (Spouse) First Name, M.I.
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Date of Birth (P)				Date of Birth (S)
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Social Security Number (P)				Social Security Number (S)
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Street Address of Residence				Bank 1 Name
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City		State	Zip Code	Branch Name
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Home Phone (Inc. Area Code) E-Mail Address				Bank Street Address
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Business Name		Position		City	State	Zip Code
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Type of Business				Acct. # Business	Acct. # Personal
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Street Address of Business				Deposit Check to	Business	Personal
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City		State	Zip Code	Bank 2 Name
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Business Phone (Inc. Area Code)				Branch Name
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Alternate Address				Bank Street Address
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City		State	Zip Code	City	State	Zip Code
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Send Credit Correspondence to				Acct. # Business	Acct. # Personal
Bus.	Res.	Alt.
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Send Marketing Correspondence to				Deposit Check to	Business	Personal
Bus.	Res.	Alt.
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GOLDEN NUGGET ENDORSES RESPONSIBLE GAMING: We will cancel or reduce your credit line upon your request. If you or anyone you know may have a problem gaming responsibly, please call 1-800-522-4700.

I give Golden Nugget and it’s representatives permission to obtain and verify credit information from any source, obtain my credit and employment history and exchange information with others about my credit and account experience with the Golden Nugget. I agree not to hold any of these entities responsible or liable for the information released. I agree that the Golden Nugget will retain this application whether or not it approves the credit line.

Before drawing on my line of credit, if granted, I agree to sign credit instruments (i.e. checkS) in the amount of the draw. I authorize Golden Nugget to complete any of the following missing items on these credit instruments: (1) the name of a payee, (2) any missing amounts, (3) a date, (4) the name, account number, and/or address and branch of any banks and financial institutions and (5) any electronic encoding of the above items. This information can be for any account from which I now have or may in the future have the right to withdraw funds, regardless of whether that account now exists and whether I provided the information on the account to Golden Nugget.

I acknowledge that irrespective of any currency exchange laws in the country in which I reside, I have the ability and intent to legally repay any advance of money by the Golden Nugget. I also acknowledge that an independent agent collecting front money deposits or payments on my debt is my agent and not an agent for Golden Nugget or any of its affiliates.

I agree that each draw against my credit line is a separate advance of money by the Golden Nugget. If I receive the advance before I execute a credit instrument, I promptly will sign a credit instrument in the amount of the advance.

I agree that Nevada law exclusively governs the terms of the credit line, advances or credit instrument. I agree that the Golden Nugget may litigate any dispute involving the credit line, the debt, or the payee in any court, state or federal, in Nevada. I submit to the jurisdiction of any court, state or federal, in Nevada.

Besides any amounts authorized by law, I will pay interest at the rate of 18% per annum from the date of execution of the credit instruments and all costs of collection, including attorneys’ fees and court costs.

Warning: For the purposes of Nevada law, a credit instrument is identical to a personal check and may be deposited in or presented for payment to a bank or other financial institution on which the credit instrument is drawn. Willfully drawing or passing a credit instrument with the intent to defraud, including knowing that there are insufficient funds in an account upon which it may be drawn, is a crime in the State of Nevada which may result in criminal prosecution in addition to civil proceedings to collect the outstanding debt.

Credit Requested $ ______________	Date________________________		Arrival Date ________________________
____________________________________________________		__________________________________________________
Primary Signature (AS IT APPEARS ON CHECKS)		Secondary Signature (AS IT APPEARS ON CHECKS)

LV-CR300 (12/06)