Checking or Credit Card Agreement

Please sign and complete this form to authorize to Biostar Organix Healthcare Association, PMMA dba/Diacom USA to debit the credit card and/or check listed below, and by signing this form you give us authorization to debit the account for the amount indicated on or after the indicated date as per the terms here within. By signing this payment plan agreement, you also agree additional conditions and fees that may be imposed due to surcharges, non-payment, chargebacks, cancellations, returns or disputes resolution.

Click here to Fill this form Online Online Payment Authorization (with eSignature)

Payment Authorization (PDF)
Click here to download the Payment Authorization (PDF)
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