Philippine Credit Card Authorization Form

To: USANA Distributor Services:

UHS Essential Health Philippines, Inc. 24th Floor, Tower 1, The Enterprise Center, 6766 Ayala Avenue corner Paseo de Roxas, Makati City, Philippines 1200 distserv@ph.usana.com Customer Service (632) 858-4500 Phone Order Line (632) 858-4599 Fax Order Line

I, _______________________________________ (name as on credit card) (USANA ID:________________), would like to authorize Mr./Ms. _____________________________________________________________ (USANA ID: _______________________) to charge his/her USANA order(s) to my credit card as detailed below.

My Credit Card Information

VISA Card Number: Card Expiration Date: __________ / __________ Month / Year MasterCard

Order:
Item(s): __________________________________________________________________________________ ________________________________________________________________________________________ Total Amount: _________________________________

I acknowledge that it is my responsibility to obtain reimbursement from the Distributor for any USANA products ordered by him/her. If the Distributor failed or refused to reimburse me for purchases made, I understand that I remain primarily responsible for making sure that USANA receives payment from my credit card company. I certify that I have obtained reimbursement from the Distributor for the USANA products ordered by him/her using my credit card. I acknowledge that all orders placed by me in my business centers are legitimate orders paid for by me or by my customers. I have reimbursed the cardholder for orders placed in my business centers paid for by his/her credit card.

Cardholder Signature
(As on credit card)

Signature
(Distributor)

Date

USANA Health Sciences, Inc.

Please make a photocopy for your records.

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