Prepayment Form Customer InformationCustomer Name* Customer Number* Customer Contact Number*Email* Pre Authorized* Yes No If yes and freight prepaid & charge, estimate Freight: *Round Up* Amount(s)Order/Invoice Number(s)Credit Card InformationCredit Card Number Expiration Date CVV2 or CVC2 Number CVV2 is the 4-digit number found on the right front of the American Express Card. CVC2 is the 3-digit number found on the back of the Visa or MastercardName as it Appears on Credit Card First Last Zip code for Credit Card Statement Wire Transfer InformationFor information on how to complete a wire transfer for invoices Received from C & A Service Inc. as agents for Trilogy Essential Ingredients. please see instructions here.Consent* I have read and understood the privacy statement*Consent* I accept and understand that the ingredients supplied by Trilogy Essential Ingredients, Inc. have not been tested, nor have they been determined safe, for inhalation or use in any electronic smoking devices, electronic nicotine delivery systems, electronic cigarettes, or other similar devices (collectively "E-Cigarettes") or in any E-Liquids used with E-Cigarettes. By receiving Trilogy Essential Ingredients, Inc. ingredients, the recipient confirms that they will not use these ingredients in connection with the manufacture and distribution of E-Cigarettes, E-Liquids, or any component thereof. WE DISCLAIM, TO THE FULLEST EXTENT PERMITTED BY LAW, ALL WARRANTIES, EXPRESS OR IMPLIED, and disclaim all liability in connection with the use of our ingredients in connection with E-Cigarettes and E-Liquids. All such risks are assumed by you and the user.*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.