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