Win/Loss or W2G

W2-G Request Form:
*One Request per Person
Please complete this form in its entirety, sign, and send back your request.
Please allow up to 30 days for your request to be processed.
A photocopy of the guest ID must ALWAYS be included with the request form when mailed, faxed, or e-mailed.
For quicker service, you may email the completed document to [email protected]

Patron’s Name:
Player’s Card #:(Please include all numbers)
Mailing address:
City:
State:
Zip:
Phone #: ( )
Fax #: ( )
Email address:
Social Security# (last 4 digits):
Date of Birth:
Information Requested: (Be as specific as possible)
(MM/DD/YYYY/Casino/Amount):
Method of Delivery: (Choose ONE)
1.) Mail:
2.) Email:
3.) Fax:

Signature:
Date:

Lady Luck Casino
Attn: Audit and Accounting
4067 National Pike
Farmington, PA 15437
Phone: (724) 329-7500
Fax: (724) 329-7268

For Internal Use Only:
Date Processed:
TM Signature/#:

Please print/complete ALL field and allow 30 days for your request to be processed.
For quicker service, you may email the completed document to [email protected]

Information for prior to June 24, 2019 can be requested from
www.myfanclubrewards.com

First Name: __________________ _ Last Name: ___________________________
Address: __________________________________________________________________________
City: ______________________ State: _______ Zip: ____________
Social Security Number (last 4 digits): ____ Date of Birth: _____________________
Phone Number: _______________ PLAYERS Club Number: _____________________
Signature: _________________________________________ Date: ___________
Requested information will be mailed to the above address unless otherwise noted. This
information is provided as a courtesy to our rated players and reflects activity based on rated
play in the table games/slots areas.

Please email your completed request and copy of your ID to [email protected],
return the request to the Players Club, or mail to:

Lady Luck Casino
Attn: Players Club
4067 National Pike
Farmington, PA 15437
Phone: (724) 329-7500
Fax: (724) 329-7268

For Internal Use Only:
Date Processed:
TM Signature/#: