Please COMPLETE & SEND to Olympiarx@yahoo.com
I,, HEREBY AUTHORIZE OLYMPIA PLAZA PHARMACY, INC TO CHARGE MY CREDIT CARD FOR THE EXACT AMOUNT OF $.
THIS PAYMENT WILL BE APPLIED TOWARD THE PURCHASE OF THE FOLLOWING: MedicationsDelivery FeesOTC (Over-The-Counter)GiftsOther
***Special order items are non-refundable.
TYPE OF CARD: MASTERCARDVISAAMERICAN EXPRESSDISCOVER
CREDIT CARD # CIN # (3-4 digits on back)
EXPIRATION DATE:
Zip Code
NAME ON CARD: SIGNATURE:
DATE:
Your message (optional)
BOTH CUSTOMER AND COMPANY AGREE THAT A SIGNED FACSIMILE IS AS ACCEPTABLE AS ASSIGNED ORIGINAL.
The undersigned hereby declares that the credit information listed above is true, accurate, and appears in the name as stated and authorization is hereby given to the above-named individuals to use these cards for purchases from Olympia Plaza Pharmacy.
