Credit Card Authorization

Please COMPLETE & SEND to Olympiarx@yahoo.com

Fill-Out Form

    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:

    ***Special order items are non-refundable.

    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.