OFFICE

OFFICE FURNITURE WAREHOUSE FACSIMILE TRANSMITTAL SHEET TO: FROM: COMPANY: DATE: PHONE NUMBER: SENDERS PHONE NUMBER: FAX NUMBER: SENDERS FAX NUMBER: RE:- CREDIT CARD AUTHORIZATION TOTAL NUMBER OF PAGES INCLUDING COVER: SENDERS EMAIL ADDRESS: CC: I authorize the billing of all transactions incurred at Office Furniture Warehouse to the credit card listed below. I agree to all terms and conditions set forth by Office Furniture Warehouse and understand that ALL SALES ARE FINAL. By signing this agreement, I relinquish the right to dispute the charge. Type of Credit Card: (Circle One) Visa Cle Master Card American Express VISA Account Number: Expiration Date: V-Code Number (3 digit number on the back of the card) Total Amount to be Charged: Invoices to be Applied: Telephone Number: Card Holder's Name as it Appears on the Credit Card: Authorized Signature: Credit Card Billing Address: City, State, Zip Code ft" Office Furniture Warehouse will not maintain a record of your credit card for future use. Therefore this information must be provided on a new form each time you use this method of payment 2099 West Atlantic Blvd Pompano Beach, FL 33069 Phone 954-968.4700 Fax 954-968-4897 EFTA00523028