861 S. Oak Park Road,
Covina, CA 91724
Tel: 877-977-0656
Fax: 800-521-4712
Credit Card Authorization Form
Sign and complete this form to authorize Cozzia USA to make a debit to your credit card listed below.
By signing this form you
give us permission to debit your
account for
the
amount indicated.
This
is permission for a
single
transaction and
does not provide authorization for any additional
unrelated debits or credits to your account.
VISA MASTER CARD AMEX DISCOVERAccount Type
Cardholder Name
Billing Address
City, State, Zip Code
Phone Number
Credit Card Number
Expiration Date
CVV
By signing, I authorize Cozzia USA to charge the credit card indicated in this authorization form according to the
terms outlined above.
I certify that I am an authorized user of the credit card and that I will not dispute the payment with my credit card
company; so long as the transaction corresponds to the terms indicated in this form.
Customer Signature:
Date:
Credit Card Order
BRI-2100
$2.80
KN-95 CE Non-sterile mask
Please complete the information below
I
authorize Cozzia USA to charge my credit card in the indicated amount above.
* 30
% deposit required, balance due upon receipt of goods
* If the actual ship date is more than 10 days from the quoted ship date, this order may be canceled and the deposit
refunded at the buyers discretion. The refund will be provided immediately.
