CREDIT CARD AUTHORIZATION FORM

| DTP Balance- US$500 Order  
       (Click on one of the above buttons to begin)
Beneficiary Information:
Payment is for Order # or User ID
Full Name 
 
Credit Card Holder Information:
Purchase Amount ($)
Card Issued By
Card Type
Card Issuer Phone No. (located on back of card)
Credit Card Account # (VISA/MC-16 digits)
(AMEX-15 digits)
CID/CVV# Expiry Date
Cardholder's Name 
                                                                   (payer's name exactly as shown on card)
Home Address

Home Telephone (country code + area code + number)
(your phone number listed with Credit Card company)
Email Address (eg. johnsmith@verizon.com)

Please charge my credit card bearing the above account number and expiry date for the total amount of $ USD. You hereby have my irrevocable authorization to charge my credit card for this amount in Any Currency using the exchange rate authorized at that time and to verify the above information with my Creditors and card issuer. I have read and agreed to all Candiamonds Inc. terms and conditions including the Diamond Deposit Agreement.


Print Full Name

______________________________________________
Signature (hand written)                                                          
Date
(mm/dd/yyyy)

**** PLEASE COMPLETELY FILL ONE FORM PER USER ID or ORDER NUMBER****
(A 6% fee will be added to all purchases using a credit card)
Please complete, sign and fax this form to FAX: (905) 364-0578 TEL: (646)-290-6583