Organic Day Spa 1111

1111 E Broward Blvd

Fort Lauderdale, FL 33301

Tel. 954.463.5554

Fax. 954.523.1199

www.organicdayspa1111.com

Release for Credit Card Authorization

I AUTHORIZE AND REQUEST ORGANIC DAY SPA 1111 TO PROCESS A CHARGE ON MY CREDIT CARD, AS INDICATED BELOW. PLEASE NOTE ALL CERTIFICATES ARE NON-TRANSFERRABLE , NON- REFUNDABLE, AND SUBJECT TO A 24 HOUR CANCELLATION POLICY.

Card Type :

Credit Card Number :

Expiration Date :

CV Number :

Cardholder Name :

Cardholder Billing Address :

City :

State :

Zip :

Charge Amount : $

I AGREE TO PAY THE ABOVE TOTAL AMOUNT ACCORDING TO THE CARD ISSUER AGREEMENT.

Cardholder's Signature :