Company Name: ___California
Citizens for Health Freedom
ID Number: ____ 39300979281218
FROM YOUR CREDIT CARD:
I authorize California Citizens for Health Freedom to
charge a monthly
amount indicated below directly to the credit card listed below:
_______________________________________
Name on credit card (exactly as printed)
_______________________________________
Billing Address for credit card (Street, Apt. #)
_______________________________________
City, State - Zip
______________________________________________________
Credit card number Expiration Date
$_______________________________________
Monthly amount I authorize you to charge
___________________________________________________________________
Signature
This authorization is valid until I provide you with written cancellation.
Please send to California Citizens for Health Freedom
8048 Mamie Ave.
Oroville, CA 95966