Name: (circle one) Mr./Mrs./Ms. (first)
______________ (last)_________________
Company _________________________________________________________
Address: __________________________________________________________
City: ______________ State: ________ Zip: _______ Country:
________________
E-Mail: ______________________ Phone: _____________ Fax:
______________
I hereby authorize
Access eNet Solutions Inc., dba HealthWorks 2000,
to debit my credit card at amount of US $ dollars (in numbers &
words):
US
$_______________________________________________________________________
Credit Card Type (circle one):
VISA
MasterCard
American Express
Credit Card #: ______-______-______-______ Expires mm/yy:
_______________
Last 3 digits on the back of the card (4
digits for AX-front of card): __ __ __
__
Signature (as on your card):
___________________________
ID or Driver's License #: _____________________
Country: ___________________
For your protection and
ours please enclose a photocopy of your Credit Card (*Both Sides
Please)
& an Identification Card or Driver's License. And
for companies, please use company stamp in a space below, sign
and fax it to us. You may use additional pages if
required.
| 
Therapeutic
Dosage
