PORCELANOSA' TILE / KITCHEN i 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 to 917-289-1228. 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 THE CARD) to charge my credit card set forth below the amount of $ 475.53 This payment will be applied to order number Card Type: VISA MASTERCARD icalciRcLE oNE) Credit Card #: Security Code Billing Address City: USD. Expiration Date: 05 / 16 (EXACTLY AS IT APPEARS ON YOUR STATEMENT) State: _a_ Zip Code: _a 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 card statement and d a•ree to •a the above total amount according to the card issuer agreement. (PRINT CARDHOLDER'S NAME) 15 E 13 (DATE) •• THE FOLLOWING PAGE LISTS THE LOCATIONS FOR THE NECESSARY CODE: CREDIT CARD AUTHORIZATION FORM SECURITY CODE LOCATIONS 600 ROUTE 17 NORTH. RAMSEY. NEW JERSEY 07446 • PHONE (201)995-1310 • FAX (201) 995-1960 EFTA00521204