12300 E. Washington Blvd. Suite K.

Whittier, CA 90606

Tel: (562)320-0298   Fax: (562)320-0314

Credit Card Authorization Form

Invoice # _______________

I_____________________________ authorize the use of the following credit card of which I am the legal cardholder of, for the purpose of purchasing from Chaba Décor / BGC Distribution

Please fill out the form below and fax to us (562) 320-0314

Company Name: __________________________ Phone:_______________________

                                                                                  Fax: ________________________

Address: _____________________________________________________________

City: _________________________ State: ______________ Zip________________

Card Information

        DISCOVER                       VISA                       MASTERCARD                AMEX

Name as it Appears on Card: _____________________________________

Billing Address: _______________________________________________________

City: _________________________ State: ______________ Zip________________

Credit Card #: _____________________________________Exp. Date____________

Card Security Code: ________________________________

For Visa, and MasterCard the security code is the last section of number with 3 digits in the signature area on back of the card.

I agree to the terms and conditions of Chaba Décor/BGC Distribution

____________________________________              __________________________

Signature                                                                       Date

Privacy Notice:

This form is used to process your credit card payment for Chaba Décor/BGC Distribution. Your credit card information will be retained in our office until your service request has been processed.