Card Transaction Authorization Form

AquaVim ®

54-08 46th St.
Maspeth, NY 11378
Tel: 718-433-2698
Fax: 718-433-4826
e-mail: sales@aquavim.com

AUTHORIZATION TO CHARGE CARD

 

I, _______________________________, hereby authorize Aqua Vim Corporation to 

charge my credit card in the amount of ______________________

Credit/Debit Card # ___________________________

Expiration Date: ______ (MM/YY)

CVV2# (last 3 or 4 digits of number located above the signature line on the back of card) 

_____                      

Billing Address:

______________________

______________________

Zip Code:___________

This is one time only transaction associated with the enclosed merchant application.

                                                                                   

 

____________________________________

________________________________           ___/___/___ Date