Full Name (as on account) * Username *
Address Line #1 *
Address Line #2
City: State * Zip/Postal Code *
Country Date of Birth / /
Home Phone * Fax Work Phone
E-mail * Last 4 Digits of Social Security Number: (U.S. Citizens)
Deposit Method(s) used (please mark the ones you have used):
NETeller: Email address registered in your NETeller account  
Other:
Wire Transfer: please fill out for eventually processing your Wire Transfer withdrawals (withdrawals over $999.99)
Bank Name: Bank Phone:
Bank Address:
ABA/Swift #: Account Number: Account Name:
*Please accept this as authorization for BetEagle.com, to draft the above listed credit card and continue such authorization until I notify BetEagle.com and the bank listed in writing.
Also remember to send us a visible copy of your driver's license or other form of official photo I.D. as well as a copy of each credit card used. In the case of having used another deposit method instead of credit card, please send in a Utility Bill (phone bill, electricity bill).

Signature (as shown in your ID) _____________________________________________ Date: ___________________