Your Gaming History Statement Will Be Emailed To The Email Address Filled Into This Form
Tax Year Requested 20232022202120202019201820172016201520142013201220112010
First Name
Middle Initial
Last Name
Date of Birth
Social Security Number
Players Club Number
Email
Your Comments
The Statement you will receive in 2-4 weeks represents play tracked in our Player Tracking System while your Prairie Band Player’s Club Card was being used.
Please read and sign below: Your request cannot be processed without your signature.
I request that Prairie Band Casino and Resort provide my historical gaming activity from all properties it or any of its subsidiaries or affiliates currently owns, operates or manages. In consideration for this information, I hereby release Prairie Band Casino and Resort, its parent and affiliated companies, and all of their respective officers, directors, employees, and agents 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 claims. I understand that the information requested is generated from internal marketing systems and is not intended to be or take the place of my own records of my gaming activity. Prairie Band Casino and Resort makes no representation or warranty, express or implied, as to the accuracy of this information or its effectiveness as proof of losses.
Electronic Signature
Patron Signature
Date
