Philippine

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

Credit Card Authorization Form

To: USANA Distributor Services:
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

MasterCard

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

I acknowledge that it is my responsibility to obtain reimbursement from the Distributor/Preferred Customer

for any USANA products ordered by him/her. If the Distributor/Preferred Customer fails or refuses to
reimburse me for purchases made, I understand that I remain primarily responsible for making sure USANA
receives payment from my credit card company.
I certify that I have obtained reimbursement from the Distributor/Preferred Customer 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)

USANA Health Sciences, Inc.

Signature

(Distributor/Preferred Customer*)

Please make a photocopy for your records.

Date

rev 0109