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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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