Cardholder Alternate Shipping Address Authorization or Non US Issued Credit Card Verification

Please complete the requested information below regarding a recent credit card charge and
request for an alternate shipping address or non US issued credit card for a purchase from
123 Online Products (Corazones Inc.):

I,__________________________________(Card Holder's Name as it appears on card) authorize

Corazones Inc. to charge my credit card __________________(card type, Visa,MC, Discover...ect.)

Number ________- x x x x - x x x x - __________, Exp Date Month___Year____ in the amount of

$________________ , on ___________________(Date) for my ordered product Inv. # ______.

The billing address for my card is:

(Name)______________________________________________________

(Company)____________________________________________________

(Address)_____________________________________________________

(City)________________________ (State)_____________ (Zip)__________

(Country)_____________________ (Phone)__________________________

I am also requesting Corazones Inc. to ship my order to the following alternate address other
than my billing address:

(Name)______________________________________________________

(Company)____________________________________________________

(Address)_____________________________________________________

(City)________________________ (State)_____________ (Zip)__________

(Country)_____________________ (Phone)__________________________

In an effort to ensure authorized transactions and acknowledgment of sales, we request that
you, as the cardholder, be aware of recent charges on credit card. By completing and signing
below you agree and authorize Corazones Inc. to charge your above named credit card for the
agreed amount and to ship the product to an address other than the billing address.

(Signature)____________________________________(Date)____________________

(Print Name)__________________________________

For International orders we also require the following:
Copy Front and Back of the Credit Card being used
Copy Front and Back of Driver's License or equivalent