To protect the credit card holder from unauthorized credit card/debit card usage, we require the following form to be completed and sent back to Hazel Peppergood. Please print this authorization form and fax to: (62) 361 232772 or scan it and send it by e-mail.

If you do not have a fax or scanner, please visit a UPS Store, Mail Boxes Etc; Staples, Office Depot, etc.

The following must be completed and signed by the cardholder.

Cardholder Name: ______________________________________________

Company: (If applicable) ________________________________________

Address: _____________________________________________________

City/State/Zip: ________________________________________________

Country: ________________________________________

Telephone: ______________________________________ E-mail address: _________________________________

I authorize Hazel Peppergood to charge my credit card/debit card for the amount of $62.00 USD and that these charges will appear on my credit card statement as PayClients.com

I understand and agree to the Terms and Conditions as outlined on Hazel Peppergood's website and refunds are made only in accordance with the special guarantee.

Signature: __________________________________________________ Date: ___________________________________________