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Chicago Prime Millionaire’s Club
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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 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). |
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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 #_________________________________________________________ |
|Purchaser Name: |
|Street Address: |
|City: |
|State: |
|Zip: |
|Phone: |
|Email: |
|Credit/Debit Card Number: |
|Card Type (circle one): AMEX Mastercard Visa Discover Diners |
|Expiration Date: |
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
Phone: 847.969.9900 | Fax: 847.969.9901
dine@
01/2016
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