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AquaVimâ

Aqua Vim Corporation

54-08 46^th Street, Maspeth, NY 11378

Tel: 718-433-2698

Fax: 718-433-4826

E-mail: Sales@4fishtank.com

E-mail: AquaVim@aol.com

AUTHORIZATION TO CHARGE CREDIT CARD

I, ___________________________________, hereby authorize Aqua Vim Corporation

to charge my credit card in the amount of $_____________________________________.

Credit Card # _______________________________________________________________________.

(16 digits V/MC/Discover or 15 digits for American Express )

Expiration Date: _________________________________________(MM/YY)

CVV2# (last 3 or 4 digits of number located above the signature line on the back of card): ___________.

Address associated with credit card statement:

__________________________________________________________________; State of ___________

Zip Code associated with credit card statement: _______________

( ) Visa ( ) MasterCard ( ) American Express ( ) Discover

This is one time only transaction associated with the enclosed merchant application.

______________________________ ________________________

Authorized Signer on Card Date