RD Wholesale Partner Credit Card Authorization

Authorized Reseller Information (please print or type)

Name as it appears on card:


Business name:
Billing Street Address:                                                                                           Office/Unit#: 
City:
State:
Zipcode:


Shipping Street Address:                                                                                       Office/Unit#:
City:
State:
Zipcode:

Business phone:
Home/Cell phone:
Email:

Credit Card Information:                                                           TYPE: (MC, VISA,AMEX,DISC)
Credit card number:                                                                                               
Expiration (MM/YY): 
Security code / CVV:  

3rd party shipping account company__________________________________Account#______________________  (true shipping fees will be charged to your shipping account. we do not charge a handling fee). 

Acknowledgement Information:  
The following people are authorized to approve purchases/charges to this account: 
 
 
 

Authorization:
By my signature I hereby authorize RealDose Nutrition to accept payments by me or others using my card. This authorization supersedes any and all previous authorizations on file with RealDose Nutrition.

Authorized signature (required): ____________________________________________________________________________________

Date:__________________________________

Please return completed and signed form by email to wholesale@realdose.com or via fax to 307-316-0381.

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