SIGNATURE FORM AND AUTHORIZATION

This form is required for identification purposes and for the security of your transaction.  This form is required within 30 days of your account opening.

Once completed, please mail the completed form to:

XpressBet LLC.

200 Race Track Road, Building 26

Washington, PA  15301

Or, you may fax to us at: 866-997-7737

Username/Account #___________

First Name_______________________       Last Name____________________

Date of Birth ___/___/___

Address__________________City_______________State_______Zip________

XPRESSFUND (ACH) AUTHORIZATION

□       Please make this my XpressFund account of record for my future use

Bank Name __________________

Transit/ABA Number___________

Account Number______________

- I hereby authorize XpressBet LLC. to initiate a debit, in the amount indicated, to my checking/savings account in the depository financial institution (Bank) identified by the routing number indicated, and bank to debit same to such account.  I acknowledge that I have received services/goods in consideration hereof and I further agree that this authorization shall be non-revocable.

- I agree to pay merchant a returned item fee of $25.00, which may be initiated to my account for the items returned unpaid.  And, in the event of returned items, I authorize XpressBet to collect returned funds from other forms of payment I have previously used to make deposits.

- Please attached a voided check

CREDIT/DEBIT CARD AUTHORIZATION

□       Please make this my Credit/Debit Card account of record for my future use

       □       Visa

       □       Master Card

       16 Digit Embossed Number:

       __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

       Expiration Date __ __/__ __

                               (MM/YY)

       CVC/CVV Code __ __ __  (3-digit code printed after the credit card number on the back of your card)

- By providing my Credit/Debit Card information, I hereby take complete responsibility for all deposits made to my account in conjunction with my password.

- I authorize credit card cash advances from this card, requested over the phone or website, be deposited into my XpressBet Account.  I understand that processing fees may apply.

- Please attach a photocopy of your credit card.

I have read and agreed to the following terms and conditions:

- I confirm that the information I have submitted is complete and accurate.

- I agree and acknowledge to be bound by and comply with the Terms of Wagering of XpressBet and that I am at least 21 years of age.

- I further acknowledge that I have completely read, understand and have received a copy of this agreement.

Signature ____________________________     Date ______________________