Smart Card Replacement Form Name on your Smart Card: Smart Card Number (if you know it): Reason you need a new Smart Card (e.g. lost, damaged, etc.): Required: For security reasons please provide: Your birthday: _____(day)_____(month)_____(year) and a copy of photo identification papers (passport, driver’s license). OLD Information NEW Information Name Street Address City State/Province Postal code Country Home Phone Work Phone Fax Number Email Address Payment Amount: The cost of replacing your Smart Card is approximately US$25. However, we understand that not all people worldwide can afford the full $25. Please indicate the amount you are paying here: Payment via Credit Card is the only payment method available for replacement Smart Cards. To authorize payment by credit card please fill in the following information Your credit card will be charged by Elan Vital, Inc., PO Box 2220, Agoura Hills, CA 91376 USA Type of Credit Card you are using: ____ Visa ____ MasterCard ____ Discover ____ American Express Name as it appears on the card: Credit card number: Card expiration date: Month Year Signature of credit card holder: Email or phone number of credit card holder: Address where credit card statements are received: When you obtain your replacement Smart Card, we ask that you destroy any Smart Card that is currently in your possession, or any lost card that you later recover. Please fax this form with a copy of a photo ID (passport, driver’s license) to: 1-818-707-6378 Or mail it to: Smart Card Office P.O. Box 2278 Agoura Hills, CA 91376, USA It will take approximately four weeks for your replacement Smart Card to be issued. Questions can be addressed via email to [email protected] SC Replace Frm Wrld16Apr05.pdf.