Win/Loss Statement
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Please print and complete this form in its entirety. Guests may enter only the last four digits of their social security number if so desired. Please mail or fax(410-629-6678) the form as per the directions below.

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Casino at Ocean Downs
Player Rewards Club
10218 Racetrack Road
Berlin, MD 21811

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Player's Club Member Information
 
 
Name 
_______________________________________________________________________________
                 
Address 
_______________________________________________________________________________
         
City 
_______________________________________
State 
__________
Zip
____________________  
          
Phone 
(         ) ______________________________
SSN 
______________________________________
   
  Players Club Account #  _____________________________________
 
Please release information concerning my slot activity for the period ending _____/_____/_____

I request that Casino at Ocean Downs provide my gaming activity for the time period as indicated. I understand that Casino at Ocean Downs makes no representation of warranty, express or implied, as to the accuracy of this information or its effectiveness as proof of losses nor is it intended to take the place of my own records of gaming activity. In consideration of providing this information, I release Casino at Ocean Downs and affiliated companies from any and all claims arising from or relating to the information and its release, and further agree to indemnify and hold those entities and persons harmless from any such claim.

   
Signature ______________________________________ Date _______________________
        

Check One:               Mail______________________               Pick-Up__________________

EMPLOYEE USE ONLY

Player's Account  ________________________________ Last Name ___________________________
                    
ID Number ________________________________ State Issued ___________________________
                    
Verified By ________________________________ Badge ___________________________
                         
Date Picked Up _________/____________/__________ Date Mailed ________/__________/________
                         
Date Win/Loss Printed ________________________________ Date Filed ________/__________/________
     
      

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