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Credit Card Charge Authorization


Authorized Charge Amount*:
Email*:

Credit Card Information

Card Holder's Name*:
Card Type*:
Credit Card Number*:
Expiration Date*:
CSC#:


Billing Information

Address*:


I hereby authorize VCC to charge the indicated credit card. I agree that this is a onetime charge that will be made as indicated above. I will NOT dispute Green Farmacy on this purchase with my credit card issuer so long as the amount in question was for services rendered prior to my purchase. I guarantee and warrant that I am the legal cardholder for this credit card and that I am legally authorized to enter into this onetime payment agreement with VCC.

Legal Name*: Today's Date*:

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