Gaming Activity Request Form Name: Passport Card Number: Date

Gaming Activity Request Form
Name: Passport Card Number: Date of Birth: Email Address: Mailing Address: City/State/Zip: Is this a change of address? ☐Yes ☐ No Telephone: Please provide me with a: ☐ Win/Loss statement for the year: ☐ Jackpot statement for the year: ☐ Promotional statement for the year: I prefer statement to be: ☐ Mailed ☐ Emailed I do hereby certify that the statements contained herein are true and correct and I hereby authorize Gun Lake Casino, its subsidiaries, affiliates, and agents, to provide to me a promotional statement, a jackpot statement, or a win/loss statement of my gaming activity derived from the above referenced account. I agree to indemnify and hold harmless Gun Lake 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 or as a result of this request. Account Holder’s Signature is Required Below Account Holder’s Signature Date If Account Holder does not present request in person, Account Holder’s signature must be notarized. Only Account Holder may receive or request a gaming activity statement. Account Holder MUST present valid Government issued photo ID acceptable to Gun Lake Casino in its sole and absolute discretion. SUBSCRIBED AND SWORN TO before me on the ______ day of __________, 20____. NOTARY PUBLIC Please present this request to the Rewards Center at Gun Lake Casino. If this request is not presented in person, request must be notarized. Please mail the original request to: Gun Lake Casino: Gaming Activity Request 1123 129th Ave, Wayland MI 49348 GUN LAKE CASINO USE ONLY Type of Valid ID Verified (Driver’s License, Passport, etc.) ID Number Verifier’s Signature and Date