Credit Application

To apply for a personal line of credit at French Lick Casino, please complete the application form below. This application contains "required fields" (*) that must be filled out completely with your personal information before it will allow you to "Submit". Once your form has been submitted, a Credit Representative will contact you regarding your application. If you need assistance completing the form, please call 1-888-936-9360 extension 5849 or 5802.

The required minimum amount for a credit line is $1500.00.

Personal Information

Credit Limit Requested (minimum of $1500):	$ .00
Customer Account #:
First Name*:
Middle Name:
Last Name*:
Alias:
Address*:
Suite/Apt #:
City*:
State*:	Please select an item.
Zip Code*:
Email Address*:
Phone Number*:	- -
Cell Number:	- -

# of Years at Address*:
Mail should be sent to*:	Home Work Alternate Please select one.

Referred by:

CCID #:
License #:

Mother's Maiden Name*:
Date of Birth*: Ex: 05/22/2012	/ /
Social Security #*:	- -

Drivers License #*:
License State*:	Please select an item.
License Expiration*: Ex: 05/2012	/

Passport #:
Passport Country:
Passport Expiration: Ex: 05/22/2012	/ /

Other ID Type:	State Federal Military
ID #:
Badge #:

Additional Information

Alternate Address:
City:
State:
Zip Code:

Alternate Phone:	- -
Alternate Email:

# of Years at Address:

Employer Information

Employer Name*:
Employer Address*:
City*:
State*:	Please select an item.
Zip Code*:

Type of Business*:
Sole Proprietorship*:	Yes No
Your Position*:
# of Years with Employer*:
Business Phone*:	- -

Bank Information

Bank #1 Name*:
Bank #1 Address*:
City*:
State*:	Please select an item.
Zip Code*:

Bank #1 Phone*:	- -

ABA Routing #*:
Bank #1 Account #*:

Bank #2 Name:
Bank #2 Address:
City:
State:
Zip Code:

Bank #2 Phone:	- -

ABA Routing #:
Bank #2 Account #:

Bank #3 Name:
Bank #3 Address:
City:
State:
Zip Code:

Bank #3 Phone:	- -

ABA Routing #:
Bank #3 Account #:

I certify that I have reviewed all of the information provided and that it is true and accurate. I authorize French Lick Resort to conduct such investigations pertaining to the above information as it deems necessary for the regulation of the Indiana Gaming Commission and I may be subject to civil or criminal liability if any material information provided by me is willfully false. I hereby authorize French Lick Resort within its sole discretion, to apply any and all chips I may redeem first to reduction of any outstanding credit balance, with the remainder, if any, to be returned to me. I hereby authorize French Lick Resort to investigate my credit record and to furnish information concerning such credit record to credit reporting agencies and other who may properly receive this information

Applicant grants permission to French Lick Resort to utilize information in this application to obtain independent credit reports. French Lick Resort will not sell, disclose, or provide any of the information to any other entity except for the purpose of investigating the credit-worthiness of the applicant.

I have read and agree with the statement above. *