NOBILIS Ship/Waive CFA: Date: Account Name: Pattern Number: Order Total: Ship to: sm: VISA Credit Card #: Expiration Date: __ Name on Credit Card: MASTERCARD _/ HS LAE prev = NOBILIS CREDIT CARD AUTHORIZATION Tel: Billing Address of card: Zip Code required: SIGNATURE: i Fax: a Hold for CFA Approval: Nobilis Customer Number: Quantity: AMERICAN EXPRESS i; ve } EFTA00521212