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 to 917-289-1228. Attn: Marisa Bordonaro

- 4 IMPORTANT. A newauthorization form is needed for every charge.

I, ████████████████████, authorize Porcelanosa New Jersey,
(CARDHOLDERS NAME EXACTLY AS IT APPEARS ON THE CARD)

to charge my credit card set forth below the amount of $ ████████ USD.

This payment will be applied to order number ████████

Card Type: [ ] VISA / MASTERCARD [x] AMEX (CIRCLE ONE)

Credit Card #: ████████████████████████

Security Code **: ██████ Expiration Date: ████████

Billing Address: 9 E. 71st St
(EXACTLY AS IT APPEARS ON YOUR STATEMENT)

City: New York State: NY Zip Code: 10021

<signature> Security Code: 
Expiration Date: 

Billing Address: 9 E. 71 St
(EXACTLY AS IT APPEARS ON YOUR
City: New York
State: NY

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) agree to pay the above total amount according to the card issuer agreement.

(PRINT CARDHOLDER'S NAME): 
(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

## CREDIT CARD AUTHORIZATION FORM (cont.)

## PORCELANOSA®
TILE / KITCHEN / BATH

•• FOR YOUR SECURITY, PORCELANOSA HAS IMPLEMENTED AN ADDITIONAL FRAUD PREVENTION TOOL. OUR NEW SECURITY MEASURE REQUIRES THE ENTRY Of A "SECURITY CODE" NUMBER ON VISA, AND MASTERCARD. THIS NUMBER IS A SECURITY FEATURE FOUND ON THESE TYPES OF CARDS ISSUED SINCE 1998. BY OBTAINING THIS NUMBER, WE ARE ENSURING THE HIGHEST LEVEL OF SECURITY FOR OUR CUSTOMERS.

## Visa and MasterCard

	- 3 digits in length

• On back of card, immediately following the account number in

the signature panel

[ ]

600 ROUTE 17 NORTH, RAMSEY, NEW JERSEY 07446 • PHONE (201)995-1310 • FAX (201) 995-1960