CREDIT CARD INFORMATION FORM ( x T 150 EAST 58'™ STREET + NEW YORK, PH ( a AX ( Salesperson: Firm / Company: N.Y. LE ; a a 10573 Phone Number : Sales Order Number: Amount to charge: Credit Card Type: Visa MC Credit Card # Card Holder Name: Expiration Date: / Statement Mailing Address Street address or PO Box City State & Zip CVV2 Code: Amex This form is the solely to provide Artistic Tile, Inc. with your credit card information. A signed copy of every charge placed is required to complete any transaction. Email address or fax number to send your receipt for signature: EFTA00521213