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AquaVim
â
54-08 46th Street, Maspeth, NY 11378 Tel: 718-433-2698 Fax: 718-433-4826 E-mail: Sales@aquavim.com E-mail: AquaVim@aol.com
AUTHORIZATION TO CHARGE CREDIT CARD I, ___________________________________, hereby authorize Aqua Vim Corporation to charge Credit Card # ___________________________________________________________. (16 digits V/MC/Dicover or 15 digits for Amex) 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
( ) Discove 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 |
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