Credit Card Authorization

1015 S. Crockeer St., S16, Los Angeles, CA 990021 Tel 213-742-9621 Fax 2133-742-9627 Em
mail [email protected]
om www.EEmeraldFash
hionLA.com
Credit Card
d Autho
orizatio
on Form
m Please print this page, com
mplete the infformation and
d fax it to us 1-213-742-9627
1
7. You may send us this form by email to
o m Your orderr will not be prrocessed until we receive this informatio
on. info@ emeraldfashionla.com
Company N
Name: CARDHOLDER INFORMATIO
ON Card Type Name on Caard: Credit Card Number : Date (mm/yyy) : Expiration D
CVV code : Billing Addrress : A VISA
MASTER DISC
COVER PLEASE CH
HECK ALL BOXES I hereeby authorize Emerald Fash
hion to proceess my orders with the cred
dit card for the
e order amount and Shipp
ping & Handlin
ng fees. I agreee that I will n
not initiate anyy dispute on tthis charge in the future, fo
or the reason o
of "No Cardho
older Autho
orization". nd ownership of credit card
d upon requesst. I will provide with copy of prooff of identity an
Signature Date

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