Win/Loss Statement Request Form

I confirm that I am the primary account holder for the Club Advantage account listed above. I have read and agree to the following: I request that Lake of the Torches Resort Casino send to me at the address listed above a Win/Loss Statement for the most recent complete calendar year for the Club Advantage account listed above. I understand that the information included on this report may not be complete with all gaming activity and that only play activity recorded while using the Club Advantage account card above is available. Lake of the Torches Resort Casino in not responsible for any errors or misinformation included within the report. By signing this request form, I agree that I am the primary account holder and have the right to receive this information. I understand that falsifying my identity is a fraudulent act and is punishable by law.

Form will be void unless full legal name for Electronic Signature is entered.

By selecting the "Confirm Electronic Signature" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "Confirm Electronic Signature" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Lake of the Torches Federal Development Corp. DBA Lake of the Torches Resort Casino. You are also confirming that you are the authorized Club Advantage member with aforementioned Club Advantage Account Number to enter into this Agreement. You further agree that the use of your E-Signature constitutes your agreement to be bound by the terms and conditions of these Disclosures and Agreement as they exist on the date of your E-Signature on this form.