ACTIVE USA, INC.
(DBA: ACTIVE BASIC)
744 E. Pico Blvd., Los Angeles, CA 90021
Tel : 213-519-9630 Fax : 213-519-9620
www.ActiveBasicUSA.com
Credit Card Authorization Form
(Please print this page, complete the information and fax it to us 1-213-5
-519-9620. You may send us this form by
email to
[email protected] Your order will not be processed until we receive this information.)
Cardholder Information
Card VISA MASTER AMERICAN EXPRESS DISCOVER
Company Name:
Name on Card:
Credit Card Number :
Expiration Date :
CVV code. :
Billing Address :
Please check all boxes
By signing below, I agree to the following:
I hereby authorize Active Basic to process my orders with the credit card for the order amount and Shipping
I hereby
• I&agree
Handling authorize
that fees. Activeany
I will not initiate Basic to process
dispute on thismy orders
charge withfuture,
in the the credit card
for the for the
reason orderCardholder
of "No amount and shipping &
Authorization".
handling fees
• I will provide
I certify with
that copy
I am anof proof of identity
authorized user ofand
thisownership ofand
credit card credit card
that upon
I will not request.
initiate any dispute on this charge for the
reason of "No Cardholder Authorization"; so long as the transaction corresponds to the terms indicated in this
form.
Signature Date
