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Get Agua Caliente Win Loss Statement

Agua Caliente Casino/ Spa Resort Casino Win/Loss Statement Request Name Casino Date of Birth Account Number Social Security Number Email Address Is this a change of address YES NO please circle Mailing Address City/State/Zip Telephone Please provide me with a statement of my gaming activity for the year 2003 2004 2005 2006 2007 2008 Please Circle If Account Holder does not present request in person Account Holder s signature must be notarized. Only Account Holder may receive or request a Win Loss Statement. Account Holder MUST present valid Government issued photo ID acceptable to Agua Caliente Casino Spa Resort Casino in its sole and absolute discretion* I do hereby certify that the statements contained herein are true and correct and I hereby authorize Agua Caliente Casino the above referenced Account. I agree to indemnify and hold harmless Agua Caliente Casino Spa Resort Casino and its respective past and present agents employees managers representatives officers directors successors and affiliated persons organizations and companies from any and all suits causes of action liabilities costs losses damages attorney s fees and expenses which I or my administrators executors agents assignees or any third party may have arising out of or relating to this request as a result of this request. In witness whereof I have executed this request at on the day of City State SUBSCRIBED AND SWORN TO before me the NOTARY PUBLIC Do Not Write In This Box For Agua Caliente Casino Spa Resort Casino Use Only Valid Government Issued Identification Type Notarized Insert Valid Government Issued Verifier s Signature and Date Photo Identification Valid Government Issued Date Received All Items Verified in Player Tracking Please present this request to the Rewards Center or Promotion Center at any Agua Caliente Casino Spa Resort Casino property. If this request is not presented in person request must be notarized* Please mail the original request to 32-250 Bob Hope Drive Rancho Mirage CA 92270 Fax 760 202-6312 401 E* Amado Road Palm Springs CA 92262 Fax 760 883-1256. Account Holder MUST present valid Government issued photo ID acceptable to Agua Caliente Casino Spa Resort Casino in its sole and absolute discretion* I do hereby certify that the statements contained herein are true and correct and I hereby authorize Agua Caliente Casino the above referenced Account. I agree to indemnify and hold harmless Agua Caliente Casino Spa Resort Casino and its respective past and present agents employees managers representatives officers directors successors and affiliated persons organizations and companies from any and all suits causes of action liabilities costs losses damages attorney s fees and expenses which I or my administrators executors agents assignees or any third party may have arising out of or relating to this request as a result of this request. I agree to indemnify and hold harmless Agua Caliente Casino Spa Resort Casino and its respective past and present agents employees managers representatives officers directors successors and affiliated persons organizations and companies from any and all suits causes of action liabilities costs losses damages attorney s fees and expenses which I or my administrators executors agents assignees or any third party may have arising out of or relating to this request as a result of this request. In witness whereof I have executed this request at on the day of City State SUBSCRIBED AND SWORN TO before me the NOTARY PUBLIC Do Not Write In This Box For Agua Caliente Casino Spa Resort Casino Use Only Valid Government Issued Identification Type Notarized Insert Valid Government Issued Verifier s Signature and Date Photo Identification Valid Government Issued Date Received All Items Verified in Player Tracking Please present this request to the Rewards Center or Promotion Center at any Agua Caliente Casino Spa Resort Casino property.

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