| First Name: * |
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| Last Name: * |
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| Address Street 1: * |
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| Address Street 2: |
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| City: * |
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| Zip Code: * |
(5 digits) |
| State: * |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: * |
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| DOB: * |
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| Players Card #:: |
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| Casinos you have played at recently:: |
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| Special Interest: |
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Airfare promotions
Concerts
NASCAR
NFR
Spa
UFC
Wine Tasting
Boxing
Golf
New Year's
Cruises
Shopping
Couples Events
Shows
Super Bowl
Visa/ Gift Cards
Pro Sporting Events
Please list any other interests you may have:
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| Casino Games:
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Baccarat
Blackjack
Pai Gow
Race/Sports Book
Slots
Bingo
Craps
Poker
Roulette
Video Poker
Please list any additional games you are interested in:
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| Other: |
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