AquaVim

Aqua Vim Corporation

54-08 46th Street, Maspeth, NY 11378

Tel: 718-433-2698

Fax: 718-433-4826

E-mail: Sales@4fishtank.com

E-mail: AquaVim@aol.com

 

                                    AUTHORIZATION TO CHARGE CREDIT CARD

 

I, ___________________________________, hereby authorize Aqua Vim Corporation

to charge my credit card in the amount of $_____________________________________.

Credit Card # ___________________________________________________________.

                        (16 digits V/MC/Discover or 15 digits for American Express )

Expiration Date: ___________________________(MM/YY)

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