54-08 46th Street, Maspeth, NY 11378
AUTHORIZATION TO CHARGE CREDIT CARD
I, ___________________________________, hereby authorize Aqua Vim Corporation to
Credit Card # ___________________________________________________________.
(16 digits V/MC/Dicover or 15 digits for Amex)
CVV2# (last 3 or 4 digits of number located above the signature line on the back of card)
Address associated with credit card statement:
Zip Code associated with credit card statement:
( ) Visa
( ) MasterCard (
) American Express
( ) Discove r
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