EFTA00544520.pdf

From: ale To: Marisa Bordonaro ca> Subject: new doc_l Date: Fri, 01 Jun 2012 17:23:17 +0000 Inline-Images: new_doc_l jpg EFTA00544520  PORCELANOSA® TILE / KITCHEN / BATH CREDIT CARD AUTHORIZATION FORM If you would like to charge a purchase to your Visa or MasterCard. AMEX please do the following: 1. Print out the form. 2. Completely fill out the form below (Please print clearly). 3. Sign the form and FAX it back toll=la. Attn: Marisa Bordonaro 4. IMPORTANT: A new authorization form is needed for every charge. authorize Porcelanosa New Jersey. (CARDHOLDERS NAME EXACTLY AS IT APPEARS ON DIE CARD) to charge my credit card set forth below the amount of 3,0sCi(05 .19USD. This payment will be applied to order numbei Card Type: VISA / MASTERCARDCaIRCLE ONE Credit Card #: Security Code **: (07 1-1 .- Expiation Date: I I 5 / 1 Billing Address: JO E/c4OTh&-i- ILie) (EXACTLY AS IT APPEARS ON YOUR STATEMENT) City: State: W Zip Code: My signature below confirms that I (a) fully acknowledge this purchase and understand the charges as set forth above: (b) have authorized Porcelanosa New Jersey, Inc. to charge the amount to the card number set forth above: (c) understand that these charges will be billed on my next credit cord statement: and (d) agree to pay the above total amount according to the card issuer agreement. 1_42J_L/12 - (DATE) (PRIM CAROL 000 ROUTE 17 NORTH, RAMSEY, NEW JERSEY 07446 • PHONE (201)995-1310 • FAX (201) 995-1960 EFTA00544521