Yes
CREDIT CARD PAYMENT FORM
Name on Card :
Card Number :
Address :
Reocurring : No
Type of Card :
Sec. Number :
Exp. Date :
(The last 3 numbers on the back
of card, or last 4 for AMEX)
BILLING
City :
Amount :
Zip Code :
State :
Reocurring Terms :
THANK YOU FOR THE OPPORTUNITY TO BE OF SERVICE!
I, _____________________, authorize Prime Anti-Aging to charge my credit card above for
agreed upon purchases. I understand that my information will be saved on file for future
transactions on my account. Authorization will remain in effect until cancelled.
824 US Hwy 1 Suite 110 North Palm Beach, FL 33408
Signature Date
__________________________ _________________