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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