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. 2. 3. 4. Print out the form. Completely fill out the form below (Please print clearly). Sign the form and FAX it back to a. Attn: PF IMPORTANT: A new authorization form is needed for every charge. , 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 / AMEX (CIRCLE ONE) Credit Card #: Security Code **: Expiration Date: / Billing Address: (EXACTLY AS IT APPEARS ON YOUR STATEMENT) City: State: Zip Code: My signature below confirms that | (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. (CARD HOLDER SIGNATURE) (DATE) (PRINT CARDHOLDER'S NAME) 600 ROUTE 17 NORTH, RAMSEY, NEW JERSEY 07446 » PHONE QS ~ Ax EFTA00521206

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PORCELANOSA* TILE / KITCHEN / BATH ** THE FOLLOWING PAGE LISTS THE LOCATIONS FOR THE NECESSARY CODE: CREDIT CARD AUTHORIZATION FORM SECURITY CODE LOCATIONS ** 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 ck of card, immediately following the acc number in the signature panel Account Number Security Code ount 600 ROUTE 17 NORTH, RAMSEY, NEW JERSEY 07446 « PHONE QS - Ax EFTA00521207