COMMERCIAL SLOT PURCHASE FORM

In order to better serve your requirements we would like to know a little more about your requirements. We do not intend to use this information for the purpose of building a database for re-sale or for a junk mailing purpose. We may however use the address you provide to verify your eligibility (Federal Law) Prohibits selling gaming equipment to areas where it is deemed to be illegal to own, whether it be for gaming purposes or not. Basically we need to establish that you are a commercial buyer and illegible for our special Internet Discount Pricing. All information garnered will be held strictly confidential.


Company/Organization Name:

Street Address:

City:

State:

Country:

First Name:

Family Name:

Middle Initial:

Position:

Email Address:

Please Enter Complete Telephone & Fax Numbers Including Country Code, City Code & Area Code. Office Telephone:

Fax:

Telephone#2:

Type of Business: Casino Reseller Broker Fund Raising Charity Government Route Indian Gaming

Other: Please Explain.

Years in Business:

Gaming License:Yes No

State: License Number:

D.O.J. Authorization:Yes No File Ref. #:

Other: Please Explain.

I am interested in the following Equipment:

Thank You for your time.

We will process the above information and issue you a special Commercial Customer discount price authorization and ID via Email ASAP.


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