Plainridge Win Line

1-866-Win-Line · 1-866-946-5463

Account Wagering Application

Complete Application and mail to:

Plainridge Win Line

Plainridge Racecourse

301 Washington Street

Plainville MA, 02762

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First name Last Name

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Address City

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State Zip Code

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Email Telephone

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Social security number Date of birth (m/d/y)

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Password P.I.N. 4 digit number

$______________________________

Amount of deposit

Please Read carefully before signing this application

I certify that I am 18 years of age or older and that the information provided in this application is correct. I hereby request that Plainridge Racecourse issue an account in my name. I agree and acknowledge to be bound by and comply with the Rules and Terms of Account Wagering of Plainridge Racecourse as listed on this application. I acknowledge that those Rules and Terms of Account Wagering are an integral part of this application. By supplying my Social Security Number, I understand that IRS winnings will be credited to my account immediately, minus any mandatory Federal and State withholdings I hereby take complete responsibility for all deposits and withdrawals made to my account with my Account Number, Password, and Pin Number.

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Signature Date

Application Must include a copy of a Photo ID

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Plainridge Racecourse Use Only

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Account Number Representative Date