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| Please fill out the following form prior to submitting your request. We require this data in order to better understand your needs for acquiring further information regarding our licensing structure. The information you provide us will be kept strictly confidential and will not be sold nor divulged to anybody. |
| How did you learn about us? | |
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Reference |
Surfing on the Net |
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A Link |
Search Engine |
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Trade Show |
A Friend |
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Have you ever owned, operated or been affiliated with a casino? |
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No, I am new to this |
Yes, an online casino(s) |
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Yes, a land based casino(s) |
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How much experience do you have in online marketing? |
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None, I am new to this |
Between 1 - 2 years |
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Between 2 - 4 years |
More than 4 years |
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How much capital do you have in reserve to start your casino operation? |
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Less than $50,000 |
$250,001 - $500,000 |
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$51,000 - $100,000 |
$500,001 - $1,000,000 |
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$100,001 - $250,000 |
Over $1,000,000 |
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How much capital do you intend to allocate towards marketing on a monthly basis? |
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Less than $10,000 |
$75,001 - $100,000 |
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$10,001 - $25,000 |
$100,001 - $150,000 |
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$25,001 - $50,000 |
$150,000 - $200,000 |
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$50,001 - $75,000 |
Over $200,000 |
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What is your target date to have your online casino in full operation? |
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ASAP |
6 to 12 months |
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In 2 months |
No rush |
| 2 to 6 months | |
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| First Name | |
| Last Name | |
| Company | |
| Address 1 | |
| Address 2 | |
| Country | |
| Phone Number | |
| Fax Number | |
| E-Mail Address | |
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| Additional Comments | |
