FLOS
CREDIT CARD AUTHORIZAION FORM
Customer Name
Company Name
Billing Address
City/State/Zip
Credit Card #
Expiration Date Security Code
Billing Tel# Fax#
Sales Order / Invoice / Account Number
Amount to be Charged
We require written authorization to charge your credit card. Your credit card details are to be provided
above and reference to the order, invoice or account number this is to be applied to and total amount to
be charged.
Your signature indicates your understanding and agreement to FLOS USA's complete terms and
conditions of sale, as well as your authorization for FLOS to charge you credit card in the amount as
stated above.
Please sign and fax this form back to us for processing.
For FLOS Showroom orders, please fax to 212-941-4763
For FLOS USA office orders, please fax to 718/875-3473
Your order will be processed upon receipt of this signed agreement.
Thank you.
Signature
Date
FLU USA, Inc. 110 York Street, 5th Floor. Brooklyn, NY 11201 tel (718) 875-3472 fax (718) 875-3473
EFTA00597453