Elite Eleven

Submit a Win/Loss Statement

By submitting a Win/Loss Statement, you are verifying that you are the owner of this Cadillac Club account and authorize Cadillac Jack’s Gaming Resort, 360 Main St., Deadwood, SD 57732 to release a win/loss statement:*

Name*
First Last
Date*
MM slash DD slash YYYY
Cadillac Club #*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Would you like your form emailed or mailed to you?*
- Email
- Mail
Consent*
I agree to the privacy policy.
By filling this form out, I confirm that all of the details are correct and accurate based on my knowledge. I have not falsified any information and agree to be contacted for any further questions.
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Comments
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Name*

First Last

Email*

Phone*

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you prefer Table Games or Slot Machines?
- Table Games
- Slot Machines
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Weekend Multiplier

Fridays & Saturdays

Submit a Win/Loss Statement

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