NEW METHOD OF PAYMENT

RxCompoundStore.Com Method of Payment

AUTHORIZATION FOR CREDIT CARD ON FILE

Facility Name: *

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Card Type: *

Visa
Mastercard
American Express
Discover

Please list anyone other than the cardholder that is authorized to use this credit card.

I hereby authorize RxCompoundStore.com, LLC to charge the credit card listed above for the payment of all prescription orders. This credit card will be kept on file and will remain in effect until the expiration of the credit card account. Applicants may revoke this credit card on file by submitting a written request to the address at the top of this form. A new form must be submitted if any information such as credit card expirations or authorized users is changed. Applicants agree to pay the cost for any returned or challenged payments. *

Clear Signature

Print Signer's Name *

First

Middle

Last

Date of Signing *

Name on Card: *

Card Number: *

Expiration Date: *

CVV Code (Security Code): *

Billing Address: *

Address Line 1

Address Line 2

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