Credit Card Ordering Information

Email address: officemanager@novavisioninc.com

Fax: After entering the information, print out and fax to: 419-353-7908

I am requesting to use my credit/debit card for payment on all future orders for my account using the following information:

1. Name (exactly as shown on the card)

2. Card Type (VISA, MasterCard, etc)

3. Card Number: (NOTE: Since email is not secure, do not email the card number - instead phone or fax us the card number)

4. Expiration Date:

5. Last 3 digits of the security code in the signature panel on back of card:

6. Mailing Address and Zip Code where billing statements are mailed:

7. The name and HOME phone number of the person authorizing the use of this card:

NOTE: All orders processed by credit & debit card payments are shipped by means which do not require a signed authorization of material receipt. If you require signed authorization to accept product, please indicate here:

______ No, I do not require signed authorization to accept product

______ Yes, only ship product which requires a signature to accept the product

Your Name: _________________________________

Company Name: _____________________________

Office Telephone: ____________________________

Fax: _______________________________________

Mailing Address: _____________________________