Cardholder Alternate Shipping Address Authorization or Non US Issued Credit Card Verification Please complete the requested information below regarding a recent credit card charge and request for an alternate shipping address or non US issued credit card for a purchase from Get Poly MVA (Global, MD): I,__________________________________(Card Holder's Name as it appears on card) authorize GetPolyMVA 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 GetPolyMVA 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 Global MD / GetPolyMVA 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)__________________________________ For International orders we also require the following: Copy Front and Back of the Credit Card Being used Copy Front and Back or Drivers License or Equivalent Mail to GetPolyMVA Shipping:, 4888 E. Tropicana STE 2 Las Vegas, NV 89121 or Fax to 702-734-6333
"Credit Card For Non Us"