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Cardholder
Alternate Shipping Address Authorization or Non US Issued
Credit Card Verification
Please
complete the requested information below regarding a recent
credit card charge and request for an alternate shipping
address or non US issued credit card for a purchase from
123 Online Products (Corazon,LLC):
I,__________________________________(Card
Holder's Name as it appears on card) authorize
OnlineSCUBA
to charge my credit card __________________(card type, Visa,MC,
Discover...ect.)
Number
________- x x x x - x x x x - __________, Exp Date Month
___Year____ in the amount of
$________________
, on ___________________(Date) for my ordered product Inv.
# ______. I am also requesting OnlineSCUBA to ship my order
to the following alternate address other than my billing
address:
(Name)
______________________________________________________
(Company)____________________________________________________
(Address)_____________________________________________________
(City)________________________
(state)_____________ (Zip)__________
(Country)_____________________
(Phone)__________________________
In an
effort to ensure authorized transactions and acknowledgment
of sales, we request that you, as the cardholder, be aware
of recent charges on credit card. By completing and signing
below you agree and authorize Corazon, LLC to charge your
above named credit card for the agreed amount and to ship
the product to an address other than the billing address.
(Signature)____________________________________(Date)____________________
(Print
Name)__________________________________
For
International orders we also require the following:
Copy Front and Back of the Credit Card Being used
Copy Front and Back or Drivers License or Equivalent
Mail
to Corazon, LLC 4888 E. Tropicana STE 2 Las Vegas, NV 89121
or Fax to 702-734-6333
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