AUTHORIZATION FOR CREDIT CARD ON FILE

Credit Card Type *

Visa
Mastercard
American Express
Discover

Please list anyone other than the cardholder that is authorized to use this credit card.

Expiration Date: *

Name on Card: *

Card Number: *

CVV Code (Security Code): *

I hereby authorize Magnefuse, LLC to charge the credit card listed above for the payment of all prescription orders. This credit card will be kept on file and will remain in effect until the expiration of the credit card account. Applicants may revoke this credit card on file by submitting a written request to the address at the top of this form. A new form must be submitted if any information such as credit card expirations or authorized users is changed. Applicants agree to pay the cost for any returned or challenged payments. *

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Print Signer's Name *

Date of Signing *

Billing Address:

Address 1 *

Address 2

City *

State *

Zip *

Form ID

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Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Country/region

Collection: Highland Collection

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