1013 Investment Blvd

Apex, NC 27502


I hereby authorize uuStar Corp to charge the credit card below for the purchase of their products, services, and or shipping/handling fees. I have read and agree to uuStar Corpí»s complete sales terms and conditions located at http://www.dailyvita.com/. My order, or purchase made against an issued quote, is subject to all sales terms and conditions, unless separately negotiated.

I understand that payment for the amount charged is solely the responsibility of the person or company whose name is on the card. I certify that I am authorized to use this card for this uuStar Corp purchases.

Please fax completed form and copy of credit card to uuStar Corp at 1-919-469-0208 or mail to address above Attention: Accounts Receivable.

Buyer's Signature:                                            

Print Your Name:                                                


Your Quote Number or Online Store Order Number:                                                      

1. Fax Copy of Credit Card (back and front)  

2. Complete Credit Card Information

Type of Credit Card (circle):            Master            Visa            Discover

Card Account Number                                                 

Expiration Date (mmyy)                                           

Name of Issuing Bank:                                                

City of Issuing Bank:                                                   

Country of Issuing Bank:                                             

Name on credit card:                                                   

CVV number (on the back of your credit card, last 3 digits):                                                    

Your Company Name (associated with credit card, if applicable):


Credit Card Billing Address (Street, State or Province, Country, Postal Code):




3. Additional Contact Information

Phone Number:                              Fax Number:                                                    


4. Complete Shipping Address. If not already provided online or on your quote. Please note no Post Office Boxes can be accepted, according to export regulations.