DS9 Document EFTA00521034

a SACCO CREDIT CARD AUTHORIZATION FORM I hereby authorize Sacco Carpet Corporation to charge my credit card in the amount of for the purchase listed below. ORDER INFORMATION Order #: Amount Charged: CREDIT CARD INFORMATION Visa K AMEX K MasterCard K Cardholder Name: Credit Card Number: Expiration Date: Security Code: Billing Address: Cardholder Signature: Date: " please fax completed form to Sacco Carpet Corp.520 Broadwa , 6'6 floor, New York, NY 10012 phone: fax: www.saccocarpet.com EFTA00521034