Aqua Vim Corporation
54-08 46th Street, Maspeth, NY 11378
AUTHORIZATION TO CHARGE CREDIT CARD
I, ___________________________________, hereby authorize Aqua Vim Corporation
Credit Card # ___________________________________________________________.
(16 digits V/MC/Discover or 15 digits for American Express )
CVV2# (last 3 or 4
digits of number located above the signature line on the back of card):
Address associated with credit card statement:
State of ___________
Zip Code associated with credit card statement:
( ) Visa ( ) MasterCard ( ) American Express ( ) Discover
This is one time only transaction associated with the enclosed merchant application.
Note: Your shipping address must be the same as billing address. If your shipping address is not the same as billing address, please pay by Paypal, or check.Thank you.
Authorized Signer on Card Date