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Credit Card For Non Us


									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,

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

(Name) ______________________________________________________



(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.


(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

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