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Cardholder
Alternate Shipping Address Authorization
Please
complete the requested information below regarding a recent
credit card charge and request for an alternate shipping
address for a purchase from 123
Online Products (Corazon,LLC):
I,__________________________________(Card
Holder's Name as it appears on card) authorize
Discount-Divers
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 Discount-Divers
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)__________________________________
Mail
to Corazon, LLC 5230 4888 E. Tropicana Ste B Las Vegas NV
89121 or
Fax to 702-734-6333
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