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| (Please print this form) Name:________________________________________________________ Address______________________________________________________ City_______________________ State_____________ Zip___________ Phone_____________________ Fax_______________________ E-Mail____________________ Date:_____________________ Please place check where appropriate. Enrollment Fee of $25. ________ AND/OR $5 for participation in DIL Gaming program.________ I hereby enclose my enrollment fee of Twenty-five dollars upon which I shall be refunded if I don't refer anyone in the next 6 months prior to my enrollment date listed above. Signed:___________________________________ I was referred by: D804 Only Cash Or International Money Order is acceptable. Please make payments by International Money order to: DIL P.O.Box 737 Kingstown, St Vincent West Indies. If you prefer to wire your fee, please Contact Us for wiring instructions. Please send this form along with your Fees. OR fax us your info at 801 457 4502 Below For Official use only _____________________________________________________ ID# assigned: ................................. Verified Fees Received: ...............................
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