1013 Investment Blvd

Apex, NC 27502

INTERNATIONAL CREDIT CARD AUTHORIZATION FORM

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 Corp¡¯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:                                                

Date:                                                                  

Your Quote Number or Online Store Order Number:                                                      

• This form must be dated and signed here before we can process your order (must be signature of cardholder above or, if using a company credit card without a name on it, a company authorized signature).

• International Customers: Your order will NOT be processed until we have your FAX or Business Identification 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:                                                    

Email:                                                                                                                     

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.