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Chicago Prime Millionaire’s Club 03/18

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|Auto Loaded Credit/Debit Card Authorization Form |

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|I __________________________________________________ hereby consent a monthly payment of $50.00 to be charged to my credit/debit card automatically on the 1st of |

|every month. |

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|As a Chicago Prime Club Member you will receive an automatically loaded gift card of $100.00 on the 1st of every month to be used towards food and beverage |

|(EXCLUDING TAX & GRATUITY). May be used at both Chicago Prime Steakhouse and Chicago Prime Italian. Must have Card with you in the restaurant to use. No |

|Exceptions. Treat the card as a credit card. |

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|Also, as a Chicago Prime Club Member you will receive special promotions listed on Facebook or in an email, nightly priority seating. The card can also be given |

|as a gift to someone of your choosing. |

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|Club Member’s Signature: __________________________________________________ |

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|Chicago Prime Steakhouse Signature: _________________________________________ |

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|Purchased Date: ___________________________________________________________ |

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|Membership Card #_________________________________________________________ |

|(ALL REQUIRED) |

|Purchaser Name: PLEASE MAKE LEGABLE |

|Street Address: |

|City: |

|State: |

|Zip: |

|Phone (Required): |

|Email (Required): |

|Credit/Debit Card Number: |

|Card Type (circle one): AMEX Mastercard Visa Discover |

|Expiration Date: |

|CVV# |

The Chicago Prime Membership card is an open cancellation policy. You may cancel at any time and there are no cancellation fees.

1444 E. Algonquin Road Schaumburg, IL 60173 1730 Bank Drive Schaumburg, IL 60173

Phone: 847.969.9900 | Fax: 847.969.9901 Phone: 847.240.1414 | Fax: 847.240.1763



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