Draft / Signature Authorization

I agree that the electronic media record of my transactions held by Betpad.com shall be used as the final determination to resolve any dispute I may have. I understand it is my sole responsibility, if applicable, to report my financial information to my respective Government, Customs, or Tax jurisdiction. I acknowledge that I have read all the information contained in the BetPad.com Legal Notices and agree to abide by all the rules, terms, conditions, and agreements therein and as amended from time to time.

(Please complete one form for each separate checking/credit card account)

Account Number: ____________________ (note: enter your Betpad.com account #)
Name: ______________________________________________________
Address Line #1: ______________________________________________________
Address Line #2: ______________________________________________________
City: _________________________________ State: ___________
Zip Code: __________
Home Phone: ______________________ Fax: _______________________
Work Phone: ____________________
E-Mail Address: ______________________________________________________
Date of Birth: _____ / _____ / _______

Credit / Debit Card:

Type of Card: _____________ (MasterCard/Visa)
Card Number: ________________________________________________
Expiration Date: _____ / _______
Name as Shown on Card: ________________________________________________

*Please accept this as authorization for Betpad.com to draft the above listed credit card and continue such authorization until I notify Betpad.com and the bank listed in writing.

Additionally, I authorize Betpad.com to issue payment in accordance with electronic requests for withdraw of funds from my account, and understand no withdraw of funds requests will be processed without a signature on file.

Signature: __________________________________ Date: ________________

PLEASE RETURN THIS FORM AS SOON AS POSSIBLE.

Via Fax: Via U.S. Mail:
614-539-1014 Betpad.com
P.O. Box  850
Grove City, OH 43123