EFTA00521213.pdf

CREDIT CARD INFORMATION FORM IR I S 'I' I C 'I' I 14 I', 150 EAST 58TH STREET • NEW YORK, N.Y. 10573 PH ( • FAX Salesperson: Firm / Company: Phone Number : Sales Order Number: Amount to charge: Credit Card Type: Visa MC Amex Credit Card # Card Holder Name: Expiration Date: CVV2 Code: Statement Mailing Address Street address or PO Box City State 8. Zip This form is the solely to provide Artistic Tile, Inc. with your credit card information. A signed copy of every charge placed is required to complete any transaction. Email address or fax number to send your receipt for signature: EFTA00521213