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NOTARY ACKNOWLEDGEMENT (Statutory Declaration/____________________) Country:_________________________ State or Province of:___________________ County of______________________________ On ___________________, before me, the undersigned, a Notary Public in and for said County and State personally appeared________________________________. Personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within Credit Card Authorization Form and acknowledged to me that said person executed it. Witness My Hand and Official Seal Notary Public in and for said County and State My Commission expires:_________________ SEAL OF THE NOTARY Note: Please be aware that an ink seal is required. Cardholder’s Signature:__________________________ Credit Card’s Number:__________________________ __________________________ PLEASE SIGN THIS FORM IN BOTH PLACES ABOVE IN FRONT OF A NOTARY PUBLIC.
FAX SIGNED FORM & LEGIBLE COPIES OF DRIVERS LICENSE OR SIMILAR, SIGNED CREDIT
CARDS, CREDIT CARD STATEMENT & OR UTILITY BILL TO
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