WIN/LOSS FORM - Wildwood Casino

WIN/LOSS FORM

Statement Year*
First Name*
Last Name*
Street Address*
Address Line 2
City*
State/Province*
ZIP Code*
Phone Number*
Email Address*
Players Club Account #
Birthday*
MM slash DD slash YYYY
Consent*
I hereby verify that I am the above person requesting the Win/Loss Statement from Wildwood Casino.*